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RC291  .D85  1889      A  treatise  on  gout/ 


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TKEATISE    ON    GOUT. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseongouOOduck 


Plate  I 


Rg.l. 


Fig.2. 


Danielsson&Co,  chromo-liih. 


PLATE    I. 

Fig.  i. — Section  through  the  proximal  phalanx  of  a  gouty  great  toe- 
joint. 

Fibrillation  and  degeneration  of  cartilage,  with  absence  of  uratic  deposit 
At  the  junction. of  the  cartilage  and  the  bone  is  seen  a  deposit  of  urate  nf 
sodium.  Uratic  deposit  is  also  observed  in  the  bone,  chiefly  occupying  the 
Haversian  canals. 


Fig.  2. — Illustrates  uratic  tophi,  much  resembling  patches  of  xanthoma, 
in  the  eyelids  of  a  gouty  man.  In  this  patient  there  were  extensive 
deposits  in  the  integuments  of  all  parts  of  the  body. 


To  face  Piatt  I.J 


A 

TREATISE    ON    GOUT. 


SIR  DYCE  DUCKWORTH,  M.D.  Edin. 

M.D.  (Hon.  Causa)  Royal  Univ.  Ireland. 

FELLOW,    AND  TREASURER,   OP  THE  ROYAL  COLLEGE  OF   PHYSICIANS   OF  LONDON  : 

HON.    FELLOW  OF  THE  KING  AND   QUEEN'S  COLLEGE   OF   PHYSICIANS 

IN  IRELAND  ; 

PHYSICIAN  TO,   AND  LECTURER  ON  CLINICAL   MEDICINE  IN, 

ST.   BARTHOLOMEW'S   HOSPITAL. 


TKHitb  frontispiece  ano  illustrations. 


PHILADELPHIA: 
BLAKISTON,     SON    AND    CO. 

1012    WALNUT    STREET. 


TO 

£be  IbononrcO  /I&emors 

OF 

SIR    GEORGE    BURROWS,    Baronet, 

M.  D. ,  D.C.L.,  LL.D.,  F.R.S. , 

PHYSICIAN   IK   ORDINARY   TO    H.M.    THE   QUEEN  ;    CONSULTING   PHYSICIAN  TO   ST.    BARTHOLOMEW'S 

HOSPITAL;    SOMETIME    PRESIDENT  OF  THE  ROYAL   COLLEGE   OF  PHYSICIANS; 

ABLEST    OP    MASTERS, 

KINDEST    OF    FRIENDS, 

I  INSCRIBE 

Qbis   IDoIume. 


"Ego  bona  saltern  fide  tradam  quae  hactenus  rescivi  omnia;  difficultates 
salebrasque  sive  rationem  morbi  ipsius,  sive  curationis  metbodum,  spectantes, 
Tempori,  duci  veritatis,  evincendas  complanandasque  relinquens." — Thomas 
Sydenham  (Tractatus  de  Podagrd,  1685). 

"PellMell,  December  10,  1687. 

"  I  bave  bin  very  careful  to  write  nothing  but  what  was  tbe  product  of  careful 
observation.  Soe  when  the  scandall  of  my  person  shall  be  layd  aside  in  my 
grave,  it  will  appear  that  I  neither  suffered  myselfe  to  be  decieved  by  indulging 
in  idle  speculations,  nor  have  decieved  others  by  obtruding  anything  to  them  but 
downright  matter  of  fact." — MS.  Letter  of  Sydenham  to  Dr.  Gould  (first  published 
in  the  2nd  edit,  of  Horce  Subsecivce.     John  Brown,  Edinburgh,  1859). 

"  A  knowledge  of  the  real  nature  of  gout  and  of  its  kindred  malady  rheuma- 
tism is,  in  my  opinion,  at  the  very  foundation  of  all  sound  pathology." — Todd. 

"The  history  and  nature  of  gout  have  yet  to  be  written." — James  Begbie. 

"  Every  fact  to  the  clinical  physician  has  its  value.  ...  A  tone  of  the  voice, 
the  play  of  the  features,  the  outline  and  carriage  of  the  body,  are  to  him  as 
invariably  related  to  the  central  conditions  which  they  reveal  as  are  the  grosser 
facts  of  Nature." — Sir  W.  W.  Gull  [Address  to  Sect,  of  Medicine,  Internat.  Med. 
Congress,  1881). 

"  The  real  physician  is  the  one  who  cures :  the  observation  which  does  not 
teach  the  art  of  healing,  is  not  that  of  a  physician  ;  it  is  that  of  a  naturalist." — 
Broussais. 


PREFACE. 


From  time  to  time  during  the  last  twelve  years,  I  have  been 
engaged  in  the  study  of  Gout,  and  have  published  some  con- 
tributions to  the  subject  in  certain  volumes  of  the  St.  Bartho- 
lomew's Hospital  Reports.  Five  or  six  years  ago,  I  determined 
to  write  a  treatise  on  Gout,  and  had  made  some  progress  with 
the  work.  Various  causes,  however,  led  me  to  falter  in  this  reso- 
lution, and  I  laid  aside  my  manuscripts.  Yet  this  subject  has 
always  had  interest  for  me,  and  I  have  never  ceased  to  study 
and  make  notes  of  it  as  opportunities  offered.  Two  years  ago, 
I  was  urged,  by  those  whose  opinion  I  value,  to  complete  the 
work  I  had  begun,  and,  with  some  misgivings,  I  resumed  it. 
The  result  I  now  venture  to  lay  before  the  Profession. 

In  doing  so,  I  cannot  but  feel  that  some  apology  is  due  for 
intruding  myself  into  the  company  (already  too  large)  of  authors 
on  this  well-worn  subject — especially  since  the  attempt  to  write 
a  work  that  should  be  worthy  of  all  that  is  now  demanded  from 
an  author  who  ventures  to  publish  a  treatise  on  a  special  disease, 
is  confessedly  difficult. 

In  the  case  of  a  malady  like  Gout,  the  task  is,  in  my  opinion, 
beyond  the  powers  of  any  one  Physician,  if  he  seeks  to  write  a 
complete  work,  and  to  bring  to  each  part  of  it  fresh  contributions 
and  new  light.  It  would  require  no  less  than  that  he  should  be, 
at  once,  a  good  Anatomist,  Physiologist,  Pathologist,  and  Chemist, 
as  well  as  a  trained  and  accomplished  clinical  observer. — One  may 
well  ask,  therefore,  who  is  sufficient  for  all  this  ?  My  own 
stand-point  throughout  the  present  work  is  that  of  a  Physician 


X  PEEFACE. 

who,  as  a  Hospital  Teacher,  has  to  study  and  treat  all  forms  of 
disease,  and  deduce  from  them  such  lessons  as  may  be  illustrated 
by  them.  My  point  of  view  is,  therefore,  very  different  from 
that  of  a  so-called  specialist,  whose  thoughts  and  practice  must 
necessarily  be  narrowed  and  warped  by  devotion  to  any  one 
subject. 

While  the  experience  of  a  disease  like  Gout  attained  in  twenty 
years  of  service  in  London  in  a  great  general  Hospital,  like  St. 
Bartholomew's,  is  necessarily  very  large,  it  is  one  of  the  privi- 
leges attaching  to  the  office  of  a  Physician  in  such  an  Institu- 
tion, that  it  absolutely  prevents  the  holder  of  it  from  becoming 
a  specialist. 

Inasmuch  as  London  practice  affords  probably  the  largest  field 
of  observation  in  the  world  for  the  study  of  Gout  and  gouty 
ailments,  it  is  only  right  that  such  opportunities  should  be 
utilized  for  the  benefit  of  the  Profession  everywhere.  Hospitals 
in  London  also  present  fuller  opportunities  for  the  study  of  the 
morbid  anatomy  of  Gout  than  are  elsewhere  available,  and  in  this 
volume  will  be  found  some  results  of  this  particular  inquiry,  for 
many  of  which  I  have  to  thank  my  friend  and  colleague,  Dr. 
Norman  Moore,  who  has  paid  much  attention  to  the  matter. 

The  classical  and  epoch-making  work  of  Sir  Alfred  Garrod  on 
Gout  still  holds,  and  will  long  continue  to  hold,  the  foremost 
place  in  the  English  language  on  the  whole  subject  of  Gout,  and 
I  must  here  express  my  indebtedness  to  that  work,  and,  no  less, 
to  many  suggestions  kindly  afforded  me  by  my  friend,  its  dis- 
tinguished author,  while  writing  this  volume. 

I  may  state  that  while  a  large  part  of  my  experience  has  come 
from  many  years'  observation  of  Gout  amongst  the  patients,  both 
at  the  Eoyal  General  Dispensary  and  St.  Bartholomew's  Hospital, 
yet  a  more  complete  knowledge  of  the  disease,  as  a  whole, 
is  due  to  an  experience  of  it  gained  in  another  line  of  prac- 
tice, and  amongst  such  classes  as  do  not  frequent  hospitals. 
With  many  of  the  phases  of  Gout  and  gouty  disease,  no  sort 
and  no  amount  of  hospital  practice  avail  to  render  the  Physi- 
cian familiar. 

I  am  of  opinion  that  many  of  our  modern  text-books  occa- 


PREFACE.  XI 

sionally  fall  short  of  completeness  and  lucidity,  because  so  much 
of  their  experience  is  drawn  from  the  hospital  side  alone.  Few 
can  doubt  that,  if  the  notes  of  private  case-books  were  subjected 
to  the  same  discipline  as  obtains  in  those  drawn  up  for  hospital- 
purposes,  some  new  chapters  in  clinical  medicine  and  prognostics 
would  have  to  be  written.  Some  of  the  greatest  clinical  masters 
have  in  this  way  added  greatly  to  the  value  of  their  writings, 
in  proof  of  which  I  would  only  adduce  the  names  of  Graves, 
Bright,  Watson,  Latham,  and  Todd. 

I  have  endeavoured  to  point  out  the  relations  of  Gout  to  other 
morbid  states,  and  its  modifying  influence  on  many  of  these. 
As  will  be  found,  I  am  old-fashioned  enough  still  to  believe  in 
the  existence  of  distinct  diathetic  habits  of  body,  and  venture 
to  think  that  such  conceptions  are  not  only  true,  but  also  very 
helpful  in  guiding  towards  a  better  treatment  of  patients  suffer- 
ing from  the  disorders  attaching  to  such  habits.  This  teaching  is 
not  in  vogue  at  the  present  moment,  and  is  believed  by  some 
rather  to  hinder  than  advance  the  progress  of  our  art.  I  am 
altogether  of  a  different  opinion. 

Many  of  the  views  expressed  in  this  work  are  such  as  have 
long  held  sway  in  the  French  School  of  Medicine.  I  have  to 
confess  myself  much  imbued  by  these,  and  would  here  express 
my  indebtedness  to  the  acumen  and  discrimination  which  have 
been  brought  to  bear  in  France  by  a  long  succession  of  eminent 
teachers  on  the  whole  subject  of  arthritic  disorders.  I  do  not 
find  myself  so  often  in  accord  with  the  teaching  of  German 
authorities  in  respect  of  Gout  and  gouty  diseases,  but  I  gladly 
claim  for  Virchow  and  Ebstein  that  they  have  each  thrown  light 
on  parts  of  the  subject  which  were  previously  wrapped  in  obscu- 
rity. I  should  fail  in  my  duty  if  I  did  not  acknowledge  how 
much  I  have  learned  from  my  distinguished  colleague,  Sir 
James  Paget,  whose  contributions  to  this,  as  to  all  subjects  on 
which  he  has  written  and  taught,  are  amongst  the  most  lucid 
and  accurate  in  our  possession.  To  the  teaching  of  my  former 
master,  Professor  Laycock  of  Edinburgh,  and  to  the  writings  of 
Mr.   Jonathan   Hutchinson,  MM.  Charcot,  Lecorche,  Rendu,  Dr. 


Xll  PREFACE. 

Latham,  of  Cambridge,    Dr.   Ord,   and  many  others,   I  am  also 
under  obligation. 

The  chapters  on  Treatment  have  been  expanded,  to  greater 
proportion  than  is  common  in  treatises  of  this  kind.  I  offer 
no  apology  for  this,  inasmuch  as  I  conceive  the  duty  of  the 
Physician  to  consist  as  much  in  averting  disease  and  treating  his 
patient,  as  in  discovering  the  nature  of  his  maladies.  Few  can 
deny  that  studies  in  pathogeny,  morbid  anatomy,  and  diagnosis 
have  of  late  years  rather  overridden  those  in  practical  thera- 
peutics. Progress  is  demanded  in  all,  and  not  in  one  only ;  but 
it  may  be  affirmed  that  the  tendency  in  modern  times  is  rather 
in  the  direction  of  a  helpless  expectancy  than  in  a  strenuous  effort 
to  apply,  for  the  patient's  comfort,  the  clinical  art  in  treatment, 
an  art  which  was,  with  some  exceptions,  in  many  ways  better 
practised  half  a  century  ago.  I  am  disposed,  indeed,  to  think 
that  Medicine  as  an  Art  is  now  in  some  danger  of  being  lost 
amidst  futile  efforts  to  exalt  it  into  an  exact  Science.  I  main- 
tain that  a  great  Physician  is,  and  must  be,  a  great  Artist. 

I  must,  further,  acknowledge  various  kinds  of  help  afforded  me 
by  Mr.  D'Arcy  Power  in  our  Hospital  Museum,  and  state  that 
I  have  had  the  advantage  of  the  skill  of  Mr.  Mark,  and  of  my 
present  senior  house-physician,  Dr.  Wynne,  in  illustrating  this 
volume,  their  original  drawings  having  been  admirably  engraved 
by  Mr.  Danielsson. 

In  the  preface  to  his  famous  Tradatus  de  Podagra,  addressed 
by  Sydenham  two  hundred  and  six  years  ago  "  to  the  most  learned 
Dr.  Short,"  he  remarked  : — "  It  is  my  nature  to  think  where 
others  read  ;  to  ask  less  whether  the  world  agrees  with  me  than 
whether  I  agree  with  the  truth  ;  and  to  hold  cheap  the  rumour 
and  applause  of  the  multitude.  .  .  .  Why  should  I  be  anxious 
about  the  judgment  of  others  ? "  Such  words  are  rarely  to  be 
found  in  any  modern  preface,  but  they  well-illustrate  the  moral 
elevation  of  that  most  eminent  man,  and  convey  a  lesson  which 
much  needs  to  be  learned  by  authors  in  our  own  time.  I  could 
wish  to  repeat  every  word  of  it  in  respect  of  this  present  effort ; 


PREFACE.  XU1 

but,  with  full  consciousness  of  the  many  imperfections  in  this 
volume,  I  will  yet  dare  to  affirm  that  I  have  sought  to  be  guided 
in  writing  it  by  those  high  traditions  which  have  come  down  to 
our  Profession,  and  which  the  English  School  of  Medicine  will 
ever  have  cause  to  venerate  as  emanating  from  the  illustrious 
Sydenham. 

The  delay  which  has  occurred  in  issuing  this  work  has,  at  all 
events,  enabled  me  to  profit  by  the  Horatian  maxim  : — "  Nonum 
jprematur  in  annum  membranis  intus  positis  ;  "  for  I  have,  happily, 
surpassed  that  period. 

Lastly,  I  will  express  my  thanks  to  my  publishers  for  much 
consideration  and  many  courtesies. 

London,  St.  Bartholomew 's  Bay,  1S89. 


CONTENTS. 


CHAP. 

I.    DEFINITION    OF    GOUT  .... 

II.    PATHOLOGICAL    DOCTRINES    CONCERNING    GOUT 

III.    PATHOGENY    OF    GOUT 

IV.    MORBID   ANATOMY   OF   GOUT 

V.    HEMATOLOGY    OF    GOUT 

VI.    UROLOGY    OF    GOUT       .... 

VII.    HEREDITARY    AND    ACQUIRED    GOUT.       ATAVISM    IN    GOUT 

VIII.    ON    CONDITIONS    ALLIED    TO    GOUT    IN    THE    LOWER    ANIMALS 

IX.    RELATION    OF    GOUT    TO    OTHER    MORBID    STATES,    AND    ITS    IN- 
FLUENCE   ON    THESE.       COMMINGLING    OF    GOUT 

X.    GOUT    IN    RELATION    TO    VARIOUS    NEUROSES 

XI.    SUGGESTIVE   METHOD    FOR   INVESTIGATION    OF    CASES    OF   GOUT 
XII.    PREMONITORY   SIGNS  OF  GOUT.      CLINICAL  VARIETIES   OF   GOUT. 
ACUTE    (REGULAR)    AND    CHRONIC    (a.    TOPHACEOUS,    B.    DE- 
FORMING)   GOUT.       GOUTY    CACHEXIA.       IRREGULAR    (INCOM- 
PLETE)   GOUT  ........ 

XIII.  VISCERAL  GOUT,  AND   GOUT  OF  SPECIAL  ORGANS  AND  TEXTURES 

XIV.  ON  THE    PROPRIETY    OF   SURGICAL    OPERATIONS    ON  THE  GOUTY 
XV.    ON    SOME    DISORDERS    SIMULATING  ACUTE  GOUT 

XVI.    SKIN-DISEASES    IN    CONNECTION    WITH    GOUT    .... 

XVII.    GOUT   IN    WOMEN.       GOUT    IN    EARLY    AND    IN   ADVANCED    LIFE 

XVIII.    PYREXIA    IN    GOUT         ........ 

XIX.    GOUT     IN     RELATION     TO     THE    VARIOUS    CLASSES    AND    AVOCA- 
TIONS   OF    SOCIETY  ....... 


PAGE 
I 

5 
i5 
56 

IJ5 
118 
128 
132 

!34 
213 
240 


243 
295 
3i5 
316 

3i7 
323 
329 

332 


XVI  CONTENTS. 

CHAP.  PAGE 

XX.    GEOGRAPHICAL  DISTRIBUTION  OF,  AND  INFLUENCE  OF   CLIMATE, 

SOIL,    WATER,    AND    SEASONS    ON,    GOUT      .  .  .  •       33^ 

XXI.    TREATMENT    OF    THE   SEVERAL  VARIETIES  OF   GOUT,  MEDICINAL, 

REGIMINAL,    AND    PREVENTIVE 345 

XXII.  ON  THE  SUITABILITY  OF  ALCOHOLIC  AND  OTHER  DRINKS, 
WITH  GENERAL  REMARKS  ON  THE  DIETARY  PROPER  FOR 
THE    GOUTY    .........       42° 

XXIII.  HYDROTHERAPY,  BALNEOTHERAPY,  AND  SEA-BATHING  IN  GOUT. 

USES    OF    FRICTION    AND    ELECTRICITY.        CLIMATIC    RESORTS 

FOR    THE    GOUTY     .  .  .  .  .  ■  •  •  43 r 

XXIV.  LIFE-ASSURANCE    IN    RELATION    TO    GOUT            .             .             -             •  45 X 
XXV.    PROGNOSIS   IN    GOUT 454 


EKRATA. 

1.  Page  63,  line  2  of  description  of  Fig.  2,  for  "reflected"  read  "transmitted." 

2.  Page  133,  line  9  from  top,  for  "Mcol"  read  "Nichol." 


A  TREATISE  ON  GOUT. 


CHAPTER  I. 

DEFINITION  OF  GOUT. 

Nothing  is  more  difficult  than  the  task  of  forming  an  exact 
definition  of  a  morbid  state.  It  is  notoriously  easier  to  criticize 
than  to  propound  one.  The  besetting  danger,  or  fallacy,  that 
must  always  underlie  attempts  in  this  direction  consists  in  the 
tendency  to  take  typical  or  exquisite  examples,  and  to  formulate 
from  them  theories  which  are  insufficiently  comprehensive. 

"  Definitions,  if  they  are  to  be  more  than  convenient  helps  to 
arrangements,  belong  only  to  sciences  more  exact  than  pathology 
can  be.  It  is  better  at  present  to  think  of  diseases  as  in  groups 
with  borders  that  are  not  clearly  marked ;  or  as  of  nations  with 
ill-defined  frontiers,  and  with  inhabitants  intermingling,  and  even 
intermarrying.  We  may  find  typical  examples,  as  of  peoples,  .  .  . 
and  may  call  them  by  distinct  names,  .  .  .  but  we  must  use 
them  very  cautiously  in  the  real  study  of  pathology."  * 

In  attempting  to  define  what,  in  the  existing  state  of  our 
knowledge,  constitutes  gout,  I  shall  take  heed  to  the  caution 
thus  expressed.  In  my  study  of  this  disease,  I  have  for  long  been 
trying  to  discover  how,  and  on  what  lines,  the  changes  proper  to 
it  work  themselves  out,  and  thus  to  be  able  to  say  in  any  given 
case,  this  is,  and  this  is  not,  a  manifestation  or  product  of  gout. 
It  is  of  the  last  importance  to  seek  to  be  thus  exact  in  the  case 
of  a  disorder  such  as  this,  because  other  pathological  conditions 
certainly  run  on  lines  almost  parallel  with  it ;  and  what  is  of  more 
consequence,  as  will  be  shown,  is  that  some  of  these  conditions 
are  occasionally  mixed  up  with  those  proper  to  gout,  thus  pro- 
ducing hybrid  states  very  difficult  to  unravel.      Throughout  this 

1  Sir  J.  Paget,  Morton  Lecture,  Roy.  Coll.  of  Surgeons,  18S7. 

A 


2  DEFINITION    OF   GOUT. 

treatise  I  propose  only  to  deal  with  such  perversions  as  are  due 
to  unequivocal  gout,  and  to  disentangle  from  them  all  changes 
and  manifestations  which  are  not  thus  fairly  to  be  explained.  I 
shall  also  beware  of  what  Mr.  Hutchinson  calls  "  a  vice  of  clini- 
cal study,"  viz.,  the  selection  of  a  few  well-marked  symptoms  in 
probably  exaggerated  cases,  the  giving  to  these  of  a  special  name, 
and  then  proceeding  to  describe  and  classify  the  disease  so  named, 
as  if  it  were  essentially  distinct,  and  needed  only  acumen  in 
diagnosis  for  its  recognition. 

Gout  is  a  constitutional  or  diathetic  malady,1  manifesting 
itself  in  very  varied  aspects.  In  its  acute  forms  it  usually,  but 
not  invariably,  presents  the  characters  of  localized  inflammation, 
accompanied  by  peculiarly  intense  pain ;  the  inflammation  in  its 
course,  and  the  attendant  pain,  being  of  a  specific  nature.  In 
its  chronic  forms  there  may  be  no  manifest  inflammatory  features, 
and  even  no  pain.  The  male  sex,  chiefly  in  the  third  decade, 
is  most  frequently  the  subject  of  the  disorder  in  the  acute  form, 
and  the  articular  system  not  seldom  bears  the  brunt  of  its  inci- 
dence. In  the  earlier  manifestations  the  inflammatory  trouble 
seizes  especially  upon  the  first  joint  of  the  great-toe,  spreading 
subsequently  to  other  articulations,  and  a  suppurative  stage  but 
very  rarely  occurs.  The  digestive  system  is  largely  involved, 
and  in  the  fully  developed  forms  of  the  malady  hardly  any  of  the 
viscera  or  textures  are  unaffected.  The  nervous  system  is  like- 
wise specially  implicated,  whether  primarily  or  not  is  as  yet  a 
vexed  question. 

The  disorder  is  either  inherited  or  newly  acquired.  In  most 
of  its  manifestations  it  is  plainly  associated  with  perturbed  rela- 
tions of  uric  acid  in  the  economy,  and  the  inflammatory  attacks 
are  accompanied  by  deposits  of  urate  of  sodium,  for  the  most  part 
in  articular  cartilages  and  fibrous  structures.  A  measure  of 
pyrexia  commonly  forms  part  of  the  acuter  gouty  processes,  but 
profound,  though  slow,  nutritional  changes  may  proceed  quietly 
in  the  chronic  forms  of  the  malady  without  any  febrile  movement. 

Gout  has  been  placed  by  some  of  the  older  nosologists  amongst 
the  order  of  Fevers,  and  has  been  described  as  "  a  tertian  fever 
terminating  in  fourteen  days."  This  definition  was  formulated 
before  the  days  of  clinical  thermometry,  and  was  manifestly  appli- 
cable only  to  acute  attacks.      Acute  gout  has  been  classed  with 

1  Hunter  thought  it  probable  that  gout  is  not  always  an  act  of  the  constitution, 
but  that  parts  may  be  so  susceptible,  or  rather  disposed  for  this  action,  that  they  may 
immediately  run  into  it  when  deranged.  Scudamore  believed,  and  I  agree  with  him, 
that  this  tendency  proved  gout  to  be  an  act  of  the  constitution. 


POOR   GOUT — POOR   MANS    GOUT. 

rheumatic  fever  as  an  "  excretory  fever."  *  Parkes  2  wrote  :  "  I 
define  gout,  after  Garrod,  as  a  febrile  affection,  with  inflammation 
about  joints,  leading  to  a  deposit  of  urate  of  soda." 

The  essential  elements  in  any  case  of  gout  relate,  therefore,  to 
peculiarity  of  diathesis,  to  diminished  alkalescence  of  blood,  owing 
to  impregnation  with  uratic  salts,  and  to  the  deposition  of  the  latter, 
especially  in  the  textures  of  joints.  Sometimes  the  local  mani- 
festations prevail  more  than  the  constitutional.  Again,  the  latter 
may  be  alone  prominent,  without  marked  articular  element  in  the 
case,  as  evinced  in  instances  of  incomplete  or  irregular  gout.  In 
some  cases  we  meet  with  alternations  of  local  and  constitutional 
disturbance. 

The  main  conception  of  gout  should  have  regard  to  its  consti- 
tutional nature,  and  to  the  essential  unity  of  the  disorder,  whether 
manifested  in  acute  and  regular,  or  in  chronic  and  irregular 
fashion.  In  one  sense  the  malady  is  always  chronic,  since  we 
must  regard  any  one  having  once  given  evidence  of  unequivocal 
gout  as  goutily  disposed  for  his  lifetime. 

Respecting  what  is  often  called  "  poor  gout,"  or  "  poor  man's 
gout,"  it  must  be  stated  that  many  of  such  cases  can  be  plainly 
referred  to  chronic  rheumatic  arthritis.  Others  are  as  plainly 
examples  of  true  gout  as  can  be  demonstrated.  They  occur 
in  persons  of  feeble  constitution  with  faulty  circulation  and 
digestive  incapacity,  and  who  are  prone  to  early  textural  decay. 
They  are  often  quite  temperate,  but  not  always  so.  Women 
are  sometimes  the  subjects  of  poor  gout.  It  may,  and  often 
does,  appear  before  the  third  or  fourth  decade ;  this  is  always 
a  feature  indicating  gravity  in  any  case,  and  is  due  to  strong 
hereditariness.  More  than  fifty  years  ago,  Dr.  Billing  wrote : 3 
"  Temperate  persons  have  gout,  because  they  have,  whether 
hereditarily  or  not,  a  feeble  nervous  system  and  weak  digestion. 
Abstemiousness  will  not  cure  such  gout,  which  is  called  '  poor 
gout,'  that  which  has  come  on  in  weak  constitutions  without 
excess."  Some  cases  of  this  class  are  simply  examples  of  incom- 
plete gout,  and,  by  excess,  they  might  eventuate  in  more  sthenic 
and  frank  forms  of  the  disease. 

I  think  I  have  made  it  plain  that  no  brief  or  trite  definition  of 
this  malady  will  suffice  to  explain  its  varied  characters.  A  fitting 
conception  of  it  now  demands,  with  increasing  knowledge,  a  com- 
prehensive survey  of  a  very  large  field  of  pathological  processes. 

1  Laycock,  Medical  Observation  and  Research,  2nd  edit.,  p.  124.    Edinburgh,  1864. 

2  The  Composition  of  the  Urine,  i860,  p.  292. 

3  Principles  of  Medicine,  p.  183. 


4  DEFINITION    OF    GOUT. 

Those  who  study  carefully  the  multiform  phases  of  any  one 
malady  lay  themselves  open  to  the  charge  of  seeing  signs  and 
symptoms  of  it  in  almost  any  case  of  disease.  The  evils  of 
specialism  are  indeed  only  too  manifest  at  the  present  time. 
Taunts  such  as  I  have  alluded  to  are  freely  cast  at  those  who  see 
"  gout "  everywhere,  and  are,  perhaps,  often  not  unfairly  cast. 
The  competence  and  honesty  of  the  observer  can  alone  shield  him 
from  such  charges.  It  is  chiefly  in  respect  of  the  imperfect 
developments  and  manifestations  of  gout  that  difficulty  arises, 
and  this  perplexity  is  only  enhanced  by  the  challenge  to  bring 
every  feature  in  every  case  to  the  ultimate  test  of  the  presence  of 
uratic  deposit.  This  is,  in  the  nature  of  things,  impossible,  and 
the  prudent  observer  must,  perforce,  fall  back  upon  as  complete 
clinical  study  as  can  be  had.  Where  this  is  cautiously  and 
honestly  attempted,  I  would  venture  to  affirm  with  Gairdner,  that 
"  the  gouty  diathesis  is  often  very  perfectly  developed  in  indi- 
viduals who  never  see  its  local  manifestations,  and  that  the 
strumous  is  not  more  frequent  than  the  gouty  habit." 

Note. — "  Gout,"  remarked  Trousseau,  "  is  an  admirable  name,  because  in 
whatever  sense  it  may  bave  been  originally  employed  by  those  by  whom  it- 
was  invented,  it  is  not  now  given  to  anything  else  than  that  to  which  it  is 
applied.  .  .  .  Tbe  name  is  all  the  better  in  that  it  has  but  little  nosological 
meaning." 1 

The  term  appears  to  be  loosely  employed  in  Germany,  where  the  disease  is 
not  prevalent.  Thus,  Dr.  Pye-Smith  affirms  that " '  Gicht'  is  popularly  credited 
with  all  the  pains  which  are  called  '  rheumatics '  in  England.  Sometimes 
'  Gicht'  is  nothing  but  bad  corns,  and  is  rarely  true  gout." 

It  is  probable  that  the  earliest  English  (Saxon)  name  for  gout  was  fotadle, 
or  foot-addle.  The  word  addle  appears  to  have  been  a  synonym  for  ailment ; 
thus,  "  Shingles  was  bight  circle  addle."  Vide  Leechdoms,  Wortcunning,  and 
Starcraft  of  Early  England,  collected  and  edited  by  Kev.  Oswald  Cockayne, 
M.A.,  Cantab.  London,  1864.  Herbarium  of  Apuleius,  vol.  i.  pp.  81,  85.  (I  am 
indebted  to  my  colleague,  Dr.  Gee,  for  this  reference.) 

Dr.  J.  Mason  Good,  in  his  Physiological  System  of  Nosology,  18 17,  p.  194, 
remarks  that  "  Gout  is  one  of  the  maladies  which  seem  to  have  been  common 
in  England  in  its  earliest  ages  of  barbarism.  It  is  frequently  noticed  by  the 
Anglo-Saxon  historians,  and  the  name  assigned  to  it  is  fot-adl." 

"Cyragra,"  so  termed  in  the  Sinonoma  Bartholomew  by  John  Marfelde, 
monk  of  the  Order  of  St.  Austin,  St.  Bartholomew's  Monastery,  London, 
edited  by  J.  L.  G.  Mowat,  M.A.,  Fell.  Pern.  Coll.  Oxon.,  Oxford,  1 882.  =  "  Gutta 
vel  dolor  in  manibus  sicut  podagra  in  pedibus." — Anecdota  Oxoniensia  (MS. 
14th  century). 

1  Clin.  Med.,  vol.  iv.  p.  359. 


CHAPTER  II. 

PATHOLOGICAL  DOCTRINES  CONCERNING  GOUT. 

I  do  not  propose  to  discuss  the  manifold  opinions  that  have  been 
entertained  through  centuries  regarding  the  nature  of  gout. 
Most  of  the  good  writers  on  the  subject  have  given  historical 
summaries,  and  few  in  recent  times  have  presented  more  readable 
accounts  of  these  than  Sir  Alfred  Garrod  1  and  Professor  Ebstein 
of  Gottingen.2 

The  term  "  gout  "  at  once  suggests  the  idea  of  a  humoral  patho- 
logy, and  this  has  been,  certainly  for  two  centuries  past,  the  most 
largely  accepted  view  in  medical  history.  The  earliest  name  by 
which  the  malady  was  known  was  "  podagra,"  a  term  still  in  use, 
and  of  value  so  far  as  it  sufficiently  expresses  the  most  obvious 
feature  of  a  typical  case  without  implying  any  theory  of  causation. 
Cullen  was  the  first  to  dispute  the  long-held  view  of  the  humoral 
pathology  of  gout,  and  in  1784  promulgated  in  its  place  a  theory 
that  the  disorder  was  one  primarily  of  the  nervous  system.3 

He  stated  that  he  adopted  this  view  from  Stahl.4  Henle  in 
I  847  published  his  opinion  that  the  origin  of  gouty  inflammation 
was  probably  to  be  found  in  the  central  nervous  system.  At  the 
present  time  the  humoral  and  neurotic  theories  are  still  in  con- 
flict, but  greater  acceptance  is  perhaps  found  for  the  former. 

Cullen's  doctrine  excited  much  interest  at  the  time  it  was  set 
forth.  His  opinion  carried  weight  everywhere,  and  his  theory 
did  not  entirely  exclude  the  views  of  the  humoralists,  for  he 
allowed  that  a  peculiar  matter  appeared  in  some  gouty  patients 
after  the  disorder  had  subsisted  for  a  long  time,  and  he  regarded 

1  Gout  and  Rheumatic  Gout,  3rd  edit.     London,  1876. 

2  Die  Natur  unci  Behandlung  der  Gicht.     Wiesbaden,  1882. 

3  First  Lines  of  the  Practice  of  Physic,  vol.  ii.  part  1,  chap.  xiv.    Edited  by  John 
Thomson,  M.D.     Edinburgh,  1827. 

4  Theoria  Medico,   Vera,  &c.     G.  E.   Stahl  (Halle,  1737).     De  Doloribus  Spasticis 
Arthritico-Podagricis,  §  xxxviii.  p.  1040. 


6      PATHOLOGICAL  DOCTRINES  CONCERNING  GOUT. 

it  as   the   effect,  but  not   the   cause,  of  the  disease.1      Senator, 
referring  to  the  views  of  the  solidists  as  represented  by  Cullen, 
remarks  that  they  have  never  been  able  to  hold  their  ground 
against  the  various  humoralistic  theories. 

Great  impetus  was  given  to  the  humoral  doctrine  by  the  dis- 
covery of  the  peccant  matter,  which  had  so  long  been  suspected." 
For  more  than  half  a  century  there  was  a  growing  suspicion  that 
lithic  (uric)  acid  was  the  malign  agent  in  inducing  gout ;  and 
although  Mr.  Murray  Forbes  in  1 79 3, 4  Wollaston,5  Parkinson,6 
Pearson,7  and  Sir  Henry  Holland8  in  this  country,  and  Andral,9 
Payer, 10  Cruveilhier,11  and  Petit  in  France,  all  regarded  gout  as 
intimately  connected  with  the  presence  of  uric  acid,  it  was  not 
till  Garrod12  unequivocally  demonstrated  the  fact  in  1848,  that 
this  discovery  made  plain  one  portion  at  least  of  the  pathology  of 
this  affection,  and  thereby  constituted  one  of  the  most  brilliant 
advances  made  in  modern  medicine. 

Thus  far  the  ground  is  clear,  and  it  is  necessary  at  this  point 
to  review  the  various  theories  which  have  been  propounded  to 
explain  the  relations  between  uric  acid  and  manifestations  of 
gouty  disease. 

Before  proceeding  to  enumerate  the  several  opinions  held 
respecting  this  relationship,  it  is  fitting  to  record  that  about  ten 
years  before  Garrod's  demonstration  that  uric  acid  was  the 
peccant  matter  of  gout,  Sir  Henry  Holland  surmised  that  "  there 
was  a  presumable  relation  between  lithic  acid  and  its  compounds 
and  the  matter  of  gout ;  "  "  that  the  accumulation  of  this  matter 
of  the  disease  may  be  presumed  to  be  in  the  blood,  and  its  retro- 
cession or  change  of  place,  when  occurring,  to  be  effected  through 

1  His  theory  was  opposed  by  Dr.  Tode  in  an  inaugural  thesis  at  Copenhagen  in 
1784,  and  by  Dr.  Luther  in  another  at  Halle  in  1786.  Sir  Charles  Scudamore  and 
Garrod  also  criticized  Cullen's  definition  and  theory  of  the  disease  in  their  Treatises 
on  Gout,  1819  and  1859.  Parkinson  alludes  to  Cullen's  theory,  and  hesitated  to 
advance  his  adherence  to  the  old  humoral  theory  in  consequence.  Vide  Preface  to 
his  Observations  on  Nature  and  Cure  of  Gout.     London,  1805. 

2  Ziemssen's  Cyclopaedia,  art.  "  Gout,"  Eng.  trans].,  p.  101. 

3  Scheele  discovered  lithic  acid  in  urinary  calculi  and  urine  in  1775-  Sydenham 
originated  this  term  ("materia  peccans  ")  in  his  famous  and  classical  Treatise,  1685. 

4  A  Treatise  upon  Gravel  and  upon  Gout,  &c. 

5  On  Gout  and  Urinary  Concretions.     Philosoph.  Trans.,  ii.  386,  1797- 

6  Op.  cit. 

7  Phil.  Trans.,  1798. 

8  Medical  Notes  and  Reflections,  p.  252,  1839. 

9  Precis  d' Anatomic  pathologique,  1829,  vol.  i.  p.  553,  and  vol.  ii.  p.  387. 

10  Traite  des  Maladies' 'des  Reins,  1839,  vol.  i.  p.  243. 

11  Atlas  d 'Anatomie  pathologique,  4e  livraison,  planche  iii. 

12  Med.-Chir.  Transactions,  1848. 


GARRODS   THEORY.  7 

the  same  medium  ;"  and  "that  an  attack  of  gout  consists  in,  or 
tends  to  produce,  the  removal  of  this  matter  from  the  circulation, 
either  by  deposits  in  the  parts  affected,  by  the  excretions,  or  in 
some  other  less  obvious  way  through  the  train  of  actions  forming 
the  paroxysm  of  the  disorder."  1 

Garrod's  theory  of  the  relation  of  uric  acid  to  gout  is  founded 
on  the  view  that  the  kidneys  fail,  either  temporarily  or  perma- 
nently, to  excrete  this  acid,  and  that  the  premonitory  symptoms, 
and  those  of  the  paroxysm,  arise  from  retention  of  excess  of  it  in 
the  blood  and  the  effort  to  expel  it  from  the  system.  He  con- 
ceived that  this  renal  incapacity,  or  a  tendency  to  it,  might  be 
transmitted  hereditarily.  He  allows,  however,  that  these  views  are 
not  by  themselves  sufficient  to  explain  all  the  phenomena  of  gout. 

In  proof  of  his  views,  he  has  demonstrated  that  prior  to,  and  at 
the  time  of,  a  seizure,  urate  of  sodium  is  present  in  abnormal 
amount  in  the  blood.      He  is  careful  to  state  that  this  condition 
may  exist  sometimes  without  any  overt  gouty  manifestation,  as,  . 
for  example,  in  cases  of  lead-poisoning.2 

He  avers  further,  that  gouty  inflammation  is  always  accom- 
panied with  deposit  of  urate  of  sodium  in  the  inflamed  part ;  that 
the  deposit  is  interstitial  and  infiltrated,  and  also  permanent.  He 
regards  the  deposition  of  urate  of  sodium  as  the  cause,  and  not  the 
effect,  of  the  gouty  inflammation.  He  believes  that  the  inflamma- 
tion in  a  gouty  attack  tends  to  the  destruction  of  the  urate  of 
sodium  in  the  blood  of  the  inflamed  part,  and  consequently  in 
the  system  generally  ;  that  the  kidneys  are  probably  implicated 
functionally  in  the  early,  and  certainly  structurally  in  the  chronic, 
stages  of  gout,  and  that  the  urine  is  altered  in  composition ; 
that  the  causes  predisposing  to  gout  are  either  such  as  pro- 
duce increased  formation  of  uric  acid  in  the  system,  or  lead  to  its 
retention  in  the  blood,  and  that  the  causes  of  a  gouty  fit  are  those 
which  induce  a  less  alkaline  condition  of  the  blood  or  augment 
the  formation  of  uric  acid,  or  are  such  as  temporarily  check  renal 
elimination  ;  that  in  no  disease  but  true  gout  is  there  deposition 
of  urate  of  sodium  in  the  tissues. 

Garrod  seeks  to  prove  his  propositions  by  clinical  and  patho- 
logical observations.  Most  of  these  views  are  now  universally 
accepted,  but  some  of  them  are  still  the  subject  of  debate,  notably 
that  in  which  he  attributes  defective  elimination  of  uric  acid  to 

1  Op.  cit.,  chap,  ix.,  3rd  edit. 

2  It  will  be  shown  subsequently  that  in  many  parts  of  Great  Britain  and  Ireland, 
and  on  the  continents  of  Europe  and  America,  lead-poisoning  is  not  found  to  be 
associated  with  gout  in  the  manner  in  which  it  undoubtedly  is  in  London. 


8  PATHOLOGICAL   DOCTRINES    CONCERNING    GOUT. 

temporary  failure  on  the  part  of  the  kidneys,  and  that  in  which 
lie  regards  uratic  deposition  as  the  cause  of  the  paroxysm,  and 
not  the  effect  of  it. 

Dr.  W.  Gairdner 1  in  his  well-known  work  combated  the  views 
of  Garrod,  and  regarded  "  the  disappearance  of  urea  and  uric  acid 
in  the  urine,  and  their  accumulation  in  the  blood,"  as  but  a  fre- 
quent symptom  and  consequence  of  gout,  itself  again  being  the 
cause  of  other  important  phenomena,  such  as  headaches,  somno- 
lence, dyspepsia,  &c.  He  was  disposed  to  attribute  the  arrest  of 
renal  function  to  some  great  emotion  or  violence  affecting  any 
great  function  of  the  body,  and  he  pointed  out  that  such  an  arrest 
was  even  more  remarkable  in  hysteria  than  in  gout.  Dr.  Gairdner's 
views  obviously  required  the  intervention  of  nervous  influence, 
though  he  did  not  thus  express  this  opinion  in  so  many  words. 

Charcot  remarks  that  Garrod's  facts  do  not  as  yet  make  a 
physiological  theory  of  gout  possible.  He  accepts  Garrod's  views 
in  the  main,  but  believes  that  the  local  changes  depend  for  the 
most  part  on  the  direct  consequences  of  the  general  change,  and 
that  gout  is  in  all  cases  a  chronic  and  constitutional  disease. 

Cruveilhier  regarded  the  deposition  of  urate  of  sodium  as  the 
cause  of  gout,  and  subsequent  attacks  as  coincident  with  fresh 
secretions  or  deposits  of  it. 

Dr.  Barclay  2  regarded  the  uric  acid  theory  as  "  far  too  mecha- 
nical." He  allowed  that  in  the  case  of  the  joints  we  find  the 
inflammation  and  the  deposit  harmonizing  together,  but  asked, 
"  Does  it  necessarily  follow  that  if,  during  the  existence  of  gout, 
inflammation  of  any  tissue  does  not  present  the  same  deposit,  it 
must  be  excluded  from  our  idea  of  the  disease?"  And  again, 
"  Must  we  of  necessity  find  urate  of  soda  in  the  stomach  and  the 
bronchi  before  we  can  admit  gouty  gastritis  or  gouty  bronchitis  ?  " 
He  thought  that  because  such  deposits  were  not  found  in  these 
situations,3  we  were  warranted  in  denying  that  "  true  gouty  in- 
flammation is  always  associated  with,  or  caused  by,  the  deposit ; " 
and  he  thought  "  this  conclusion  acquired  additional  force  from 
the  consideration  that  though  the  deposit  and  the  inflammation 
were  associated  together  in  the  joints,  the  urate  of  soda  was  seen 
in  other  parts  without  any  evidence  of  its  exciting  inflammation 
there."  Barclay  believed  the  first  change  to  be  in  the  molecular 
structure  of  the  blood  itself,  this  being  set  up  by  the  repeated 

2   Gout,  its  History,  its  Causes,  and  its  Cure.     London,  1849,  v.  p.  99  ;  3rd  edit., 
p.  88,  1854. 

2  On  Gout  and  Rheumatism  in  Relation  to  Disease  of  the  Heart.     London,  1866. 

3  "  Bence  Jones  found  a  deposit  of  crystallized  urate  of  soda  in  the  walls  of  the 
bronchial  tubes."      Vide  Garrod,  op.  cit.,  p.  204,  3rd  edit. 


PARKE8     AND    LAYCOUKS   THEORIES.  9 

introduction  of  gout-producing  elements  into  the  circulation. 
The  blood-globules  having  received  a  certain  impress,  were  suc- 
ceeded by  others  which  had  a  general  resemblance  to  them,  and 
thus  a  morbid  tendency  came  to  be  transmitted.  He  believed 
"  the  retention  of  uric  acid  to  be  a  symptom,  a  consequence  of  the 
attack  of  gout,  and  not  its  cause.  The  good  living  and  the  stimu- 
lants do  not  simply  cause  an  excess  of  uric  acid  to  be  formed,  but 
they  end  by  causing  some  more  permanent  change,  and  probably 
one  affecting  the  blood-globules,  which  reacts  on  the  kidney,  put- 
ting a  stop  to  the  excretion  of  uric  acid,  and  causing  its  retention 
in  the  serum,  where,  passing  in  the  round  of  the  circulation,  it  is 
very  apt  to  become  deposited  as  urate  of  soda."  The  effects  of 
colchicum  in  checking  a  gouty  paroxysm  he  believed  to  indicate 
"  that  there  is  a  disease  to  which  the  name  '  gout '  is  applied, 
distinct  from  the  excess  of  uric  acid  in  the  blood-serum  which 
attends  its  progress."  The  fact  that  alkaline  remedies,  which,  if 
the  purely  chemical  theory  were  true,  should  readily  neutralize 
and  lead  to  elimination  of  the  peccant  matter,  do  not  materially 
influence  the  progress  of  gouty  inflammation,  he  thought  pointed 
in  the  same  direction. 

Dr.  Parkes  was  of  opinion  that  the  elimination,  and  not  the 
formation,  of  uric  acid  was  impeded  in  gout,  and  that  there  was 
probably  increased  production  of  it  in  the  system.  He  doubted 
the  inadequacy  of  the  kidney,  as  alleged,  to  excrete  it,  and  sur- 
mised that  there  was  some  peculiar  and  unnatural  combination  in 
the  blood  or  organs  which  held  back  this  and  some  other  sub- 
stances, notably  phosphoric  acid.  "  If  this  be  the  case,  the  defi- 
cient elimination  is,  as  it  were,  only  a  consequence  of  more 
important  antecedent  aberrations  in  metamorphosis,  of  which  im- 
peded excretion  is  a  natural  sequence.  What  these  are,  how- 
ever, is  quite  unknown  ;  but  an  unnatural  formation  of  uric  acid, 
either  from  food  or  tissues,  may  possibly  be  part  of  them."  1 
Later  researches  add  force  to  these  prescient  views. 

Professor  Laycock  considered  Garrod's  theories  inadequate  for 
the  explanation  of  the  whole  phenomena  of  gout.  In  his  lectures 
at  Edinburgh,  twenty-five  years  ago,  he  taught  that : — 

(a.)  Gout  is  not  necessarily  articular,  nor  even  associated  with 
articular  inflammation. 

(b.)  Gout  is  characterized  not  by  urates  in  the  blood,  but  by 
the  genesis  of  uric  acid  in  the  tissues,  and  its  action  thereon,  and 
is  especially  characterized  by  peculiar  changes  in  the  innervation  of 
the  individual. 

1  On  Urine,  p.  298.     E.  A.  Parkes,  M.D.     London,  i860. 


IO  PATHOLOGICAL   DOCTRINES    CONCERNING    GOUT. 

Dr.  Edward  Liveing1  has  expressed  his  doubt  as  to  the  depend- 
ence of  the  phenomena  of  gout  upon  the  associated  presence  of 
uric  acid  in  the  blood,  because  excess  of  this  matter  is  found 
in  other  pathological  states  which  have  no  connection  with 
gout,  and  he  believes  that  many  of  the  features  of  the  malady 
betoken  a  nervous  origin. 

Sir  William  Roberts 2  accepts  Garrod's  teaching.  He  thinks 
that  the  defective  power  in  the  kidneys  to  eliminate  uric  acid 
probably  arises  from  diminished  alkalescence  of  the  blood. 

A  very  different  view  has  been  set  forth  by  Dr.  Ord  3  in  an 
original  and  thoughtful  essay.  He  regards  gout  as  arising  from 
a  tendency  to  a  special  form  of  degeneration  or  want  of  tissue 
organization  in  some  of  the  fibroid  tissues,  either  inherited  or 
acquired,  wherein  an  excessive  formation  of  urate  of  soda  occurs, 
and  whence  this  salt  is  discharged  into  the  blood,  and  also  de- 
posited promiscuously  in  such  parts  as  are  least  freely  supplied 
with  vascular  and  lymphatic  structures — to  wit,  cartilage.  The 
paroxysms  of  gout  he  would  attribute  to  special  local  existing 
causes,  as  injuries,  exposure  to  cold,  and  the  like.  Dr.  Ord  thus 
believes  that  the  uratic  deposits  are  not  to  be  regarded  as  signi- 
ficant of  their  elimination  from  the  blood,  that  the  local  processes 
are  not  dependent  on  these  deposits,  and  that  the  latter  are  not 
the  result  of  the  inflammation.  He  takes  cognizance  of  nervous 
influence  so  far  as  to  admit  that  "  all  authors,  in  one  way  or 
another,  admit  the  direct  influence  of  the  nervous  system,"  and 
he  believes  that  local  gouty  "  degeneration  and  inflammation  tend 
to  infect  the  rest  of  the  system  through  the  blood,  and  to  set  up 
similar  actions  elsewhere  through  reflex  nervous  influence." 

This  theory,  then,  is  a  return  in  part  to  the  views  of  the  old 
solidists,  set  forth  according  to  modern  ideas ;  but  it  is  partly 
neuro-humoral,  and,  in  any  case,  combative  of  Garrod's  theory. 
It  opens  up  very  suggestively  the  large  question  whether  or  not 
there  be,  as  part  of  the  intimate  nature  of  gout,  a  specific  ten- 
dency to  degeneration  and  abnormal  transformation  of  certain 
tissues  leading  to  uratic  deposit ;  and  a  definite  reply  to  this  is 
not  yet  forthcoming. 

Suggestive  views  on  the  relation  of  uric  acid  to  gout  have 
been  set  forth  by  Dr.  Ralfe,4  who  believes  the  first  step  in  the 

1  On  Megrim,  Sick  Headache,  and  some  Allied  Disorders,  p.  404.    London,  1873. 

2  On  Urinary  and  Renal  Diseases,  p.  66,  3rd  edit.,  1882. 

3  St.  Thomas'  Hosp.  Reports,  New  Series,  vol.  iii.  p.  227,  1872  ;  and  Med.  Times 
and  Gazette,  vol.  i.  p.  233,  1874. 

4  Clinical  Chemistry,  p.  295,  1883. 


RALKKS  AND    MURCHISON  S    THEORIES.  II 

production  of  the  disease  to  be  diminished  alkalinity  of  the  blood 
by  reason  of  the  accumulation  in  it  of  acid  and  acid  sail 

He  believes  that  uric  acid  is  formed  in  health  and  disease  in 
but  minute  quantities,  and  that  deposition  of  it  is  due  rather  to  its 
insolubility  than  to  excessive  production  of  it.  In  this  view,  the 
uratic  deposits  are  a  consequence,  and  not  the  cause,  of  the  dis- 
orders commonly  attributed  to  them. 

Garrod  found  the  reaction  of  the  blood  in  chronic  gout  to  be 
nearly  neutral.  Retention  in  the  system  is  due  to  a  fault  in  the 
tissues,  leading  to  incomplete  elimination.  The  amount  thrown 
out  by  the  kidneys  is  believed  to  be  that  formed  by  those  organs, 
and  at  once  discharged  instead  of  being  destroyed. 

The  diminution  of  uric  acid  in  the  urine  is  found  chiefly  in 
chronic  gout  where  the  kidneys  are  already  damaged,  and  hence 
Dr.  Ralfe  is  disposed  to  doubt  Garrod's  theory  that  the  failure 
in  renal  elimination  is  the  prime  cause  of  the  retention  of  uric 
acid  in  the  system,  and  he  believes  that  "  the  first  step  in  the 
process  lies  in  the  failure  of  the  tissues  to  reduce  the  acid,  as 
occurs  in  health.  In  the  large  glands,  or  where  the  current  of 
the  circulation  is  free,  the  uric  acid  is  carried  into  the  blood,  and 
gradually  reduced  to  urea;  in  tissues  outside  the  current  of  the 
circulation,  the  insoluble  uric  acid  is  not  so  readily  carried  off, 
and  so  on  the  slightest  disturbance  is  deposited,  as  is  the  case  in 
cartilages  of  the  joints,  the  ear,  &c."  Dr.  Ralfe,  then,  accepts 
Dr.  Ord's  views  as  to  textural  degeneration,  either  hereditary  or 
acquired,  in  which  the  tissues  and  blood  become  loaded  with 
effete  products,  and  he  next  invokes  the  agency  of  the  nervous 
system,  supposing  that  "  such  predisposing  conditions  lead  at  last 
to  disturbance  of  some  special  nerve-centre,"  which  constitutes 
the  determining  cause  of  the  gouty  attack,  "  the  result  of  which 
is  the  accumulation  of  uric  acid  in  the  blood,  and  the  deposition 
of  urate  of  soda  in  the  tissues."  These  views  are  partly  solidistic 
and  partly  neuro -humoral. 

I  may  now  mention  the  views  of  the  late  Dr.  Murchison,1  who 
regarded  gout  merely  as  a  result  or  variety  of  lithasrnia.  This 
condition  of  the  blood  is  recognized  on  all  hands  as  due  to 
imperfect  digestion  and  functional  derangement  of  the  liver. 
"  Articular  gout  is,  so  to  speak,  a  local  accident,  which,  though 
sometimes  determined  by  an  injury,  yet  may  occur  at  anytime  in 
persons  in  whom  the  normal  process,  by  which  albuminous  matter 
becomes  disintegrated  in  the  liver  into  urea,  is  persistently  de- 
ranged.     In  other  words,  gout,  like  diabetes,  is  the  result  of  a 

1  Lecture  on  Diseases  of  the  Liver,  2nd  edit.,  p.  568,  1877. 


12  PATHOLOGICAL    DOCTRINES    CONCERNING    GOUT. 

functional  derangement  of  the  liver."  Murchison  accepted  Garrod's 
views  as  to  previous  accumulation  of  uric  acid  in  the  blood,  and 
failure  of  renal  action  in  elimination  of  it  at  the  later  stages  of 
gout,  though  he  pointed  out,  as  Garrod  did,  that  the  kidneys  are 
generally  healthy  at  the  first  onset.  He  believed  that  the  innate 
defective  power  of  the  liver,  whereby  its  functions  are  readily 
deranged,  is  capable  of  hereditary  transmission,  and,  so,  often 
passed  on  to  the  offspring.  Hence,  as  Bristowe  points  out,  gout, 
according  to  Murchison,  would  bear  something  of  the  relation  to 
the  liver  that  ursemic  dropsy  does  to  the  kidney. 

Professor  Latham,  of  Cambridge,  has  discussed  the  relations  of 
uric  acid  to  gout,  and  the  recondite  question  of  the  formation  of 
uric  acid  in  animals.1 

He  holds  a  very  similar  opinion  to  that  expressed  by  Murchison 
as  to  the  hepatic  origin  of  gout,  and  states  :  "  Just  as  in  diabetes 
the  essential  fault  lies  in  the  inability  of  the  system,  either  in  the 
liver,  or  it  may  be  elsewhere,  to  effect  the  metabolism  of  glucose, 
which  then  passes  into  the  circulation  and  is  discharged  by  the 
kidneys,  so  in  gout  or  gravel  the  imperfect  metabolism  of  gly- 
cocine "  (a  derivative  of  glycocholic  acid)  "  is  the  primary  and 
essential  defect.  Unchanged,  it  passes  from  the  alimentary  canal, 
or  elsewhere,  into  the  liver ;  there,  under  the  action  of  the  gland, 
it  is  conjugated  with  urea,  resulting  from  the  metabolism  of  the 
other  amido-bodies,  leucine,  &c,  and  is  converted  into  hydantoin, 
or  a  kindred  body,  then  passes  on  to  the  kidneys,  to  be  combined 
there  with  another  molecule  of  urea  forming  ammonium  urate,  a 
portion  of  which  overflows  into  the  circulation,  and  is  converted 
into  sodium  urate."  Dr.  Latham  believes,  further,  that  there  is 
some  change  in  the  nervous  system  which  determines  the  attacks, 
their  incidence  on  the  joints,  and  the  hereditary  nature  of  gouty 
disease. 

Mr.  Jonathan  Hutchinson,2  as  the  result  of  large  experience 
and  much  thought,  has  promulgated  some  noteworthy  and  impor- 
tant views  in  respect  of  the  relation  of  uric  acid  to  gout.  In 
subsequent  chapters  I  shall  have  occasion  to  refer  to  many  of  the 
doctrines  on  the  whole  subject  of  gouty  disease  which  have  been 
laid  down  by  this  eminent  observer. 

He  accepts  as  undoubted  evidence  of  true  gout  all  cases  of 
arthritis  and  inflammation  of  fascia  and  allied  structures  which 

i  On  the  Formation  of  Uric  Acid  in  Animals  :  its  Relation  to  Gout  and  Gravel. 
Cambridge,  1884.  Vide  also  Croonian  Lectures,  1886.  Royal  College  of  Physicians. 
London,  1887. 

2  On  the  Relations  which  Exist  between  Gout  and  Rheumatism.  Trans.  Internat. 
Med.  Congress,  London,  1 88 1,  vol.  ii.  p.  92. 


HUTCHINSON  8   AND    EBSTEIN  S    VIEWS.  I  3 

occur  in  association  with  accumulation  of  urate  of  soda,  this  fact 
being  proved  after  death,  or  by  examination  of  the  blood  or  urine 
during  life.  But  he  believes  that  we  are  not  to  wait  for  proof  of 
the  presence  of  this  salt  in  the  blood,  far  less  of  its  deposit  in  the 
tissues,  before  we  are  entitled  to  use  this  terra.  Whatever  can 
be  proved  to  be  connected  with  tendency  in  this  direction  must 
rank  as  gout,  though  there  may  be  only  dietetic  idiosyncrasy,  but 
no  tophi,  lithasmia,  or  arthritis.  "  Much  that  occurs  in  connection 
with  inherited  gout  in  young  people,  and  many  forms  of  '  quiet 
gout '  in  those  who  have  both  inherited  and  acquired  it,  is  pro- 
bably without  any  proved  tendency  to  the  accumulation  of  lithates. 
The  gout-process  is  partly  due  to  defective  assimilation,  and  partly 
to  deficient  excretion,  and  it  is  probably  only  when  the  kidneys  are 
decidedly  affected  that  any  great  tendency  to  the  formation  of 
tophi  is  witnessed.  It  is  possible,  indeed  probable,  that  in  some 
of  the  inherited  forms  neither  digestion  nor  excretion  is  much 
impaired,  and  that  the  inheritance  is  of  peculiarity  of  tissue." 
Mr.  Hutchinson  believes  in  a  basic  arthritic  diathesis,  and  that 
upon  this  may  be  built  up,  under  the  influence  of  special  causes, 
a  tendency  to  gout,  rheumatism,  or  any  one  of  their  various 
modifications  and  combinations.  Hence,  he  regards  gout  as,  in 
many  cases,  but  a  superaddition  to  rheumatism. 

Ebstein's  1  views  differ,  in  some  respects,  from  most  of  those  I 
have  mentioned.  He  found,  after  a  study  of  many  of  the  affected 
tissues  in  gout,  that  one  change  is  common  to  all  of  them,  inde- 
pendently of  the  uratic  crystallizations,  and  that  is,  a  necrosis  of 
the  parts  wherein  such  depositions  take  place.  He  regards  such 
necrosis  in  gout  as  equally  characteristic  as  is  uratic  deposit. 
Both  changes  must  coexist  in  any  texture  in  order  to  constitute 
truly  gouty  patch ;  and  he  has  detected  such  patches  in  the 
kidneys,  in  hyaline  and  fibro-cartilage,  tendons,  and  connective 
tissue.  He  calls  attention  to  an  early  stage  of  this  necrosing 
process,  in  which  as  yet  no  deposition  has  occurred,  and,  therefore, 
maintains  that  nutritive  tissue-distui'bance  is  the  primary  factor, 
and  uratic  crystallization  the  secondary  one  in  the  gouty  process, 
this  last  not  occurring  before  complete  death  of  the  damaged 
texture.  He  has  never  seen  crystallized  urates  in  healthy  tissue. 
With  Garrod,  he  agrees  that  uric  acid  is  excreted  at  first  in  liquid 
form  as  sodium  urate  into  certain  textures,  becoming  rapidly 
inspissated,  owing  to  its  insolubility,  and  tending  to  crystallize 
out  and  solidify.  He  maintains  that  this  compound  is  a  directly 
poisonous  irritant  wherever  deposited,  the  injurious  effects  vary- 

1  Op.  cit. 


14  PATHOLOGICAL    DOCTRINES    CONCERNING    GOUT. 

ing  according  to  the  quantity  and  concentration  of  the  uratic 
deposit,  and  also  according  to  the  vulnerability  of  the  special 
tissue  involved,  firm  textures  resisting  this  process  better  than 
those  of  looser  character.  He  regards  this  incrustation  as  ana- 
logous to  calcification,  in  which  lime-salts  are  deposited  in  tissues 
whose  nutrition  is  greatly  or  completely  destroyed.  As  will  be 
shown  later  on,  Cornil  and  Ranvier  maintain  that  uratic  deposit 
occurs  primarily  in  cells,  penetrating  subsequently  into  the  neigh- 
bouring ground- substance,  notwithstanding  the  resistance  offered, 
whereas  in  calcification  the  infiltration  begins  primarily  in  the 
ground-substance.  Ebstein  admits  that  lime-salts  may  be  sub- 
sequently deposited  in  gouty  tissues,  just  as  in  the  case  of  other 
necrosed  textures. 

Having  now  given  a  summary  of  the  principal  doctrines  which 
have  been  laid  down  by  the  best  authorities  respecting  the  rela- 
tions of  uric  acid  to  the  specific  manifestations  of  gout,  I  am  in  a 
position  to  discuss  these,  and  to  offer,  as  concisely  as  possible, 
the  views  which  best  commend  themselves  to  me  as  illustrating 
the  pathogeny  of  the  disorder.  This  I  propose  to  do  in  the  next 
chapter. 


CHAPTER  III. 

THE    PATHOGENY   OP    GOUT. 

"  Pathology  is  a  part  of  biology,  and  not  derived  chiefly  from  the  study  of  ana- 
tomy and  chemistry." — Paget. 

"  No  very  limited  theory,  and  no  one  particular  hypothesis,  can  be  found  applicable 
to  explain  the  whole  nature  of  gout." — Scudamoke. 

It  may  be  confidently  asserted  that,  according  to  present  know- 
ledge, no  conception  of  this  malady  is  possible  which  should 
exclude  from  its  purview  the  part  played  in  it  by  uric  acid. 
This  is,  without  doubt,  the  peccant  matter  which  works  much 
of  the  varied  and  far-reaching  mischief.  It  will,  however,  be 
shown  that  the  peculiarly  perverted  relations  of  uric  acid,  even 
in  true  gout,  do  not  constitute  the  whole  of  the  disorder.  In 
spite  of  teachings  to  the  contrary,  I  would  affirm  at  the  outset 
that  this  part  of  the  pathogeny  of  gout  is  certain,  so  that  it  may 
be  plainly  stated — "No  uric  acid,  no  gout."  That  I  may  not 
be  misunderstood  hereafter,  I  would  express  my  adherence  to  the 
view  that  the  most  unequivocal  evidence  of  true  gouty  disease  is 
that  derived  from  the  presence  of  uratic  salts  in  the  tissues;  and, 
I  suppose,  no  one  differs  from  this  view  thus  stated.  This  de- 
position, however,  is  a  manifestation  of  the  extremest  and  most 
gross  change  that  can  be  wrought  in  any  case.  I  am  confident 
that  much  gouty  disease  and  many  textural  changes  can  also  be 
induced  without  this  specific  deposit  in  overt  form,  and  I  shall 
seek  to  give  proof  of  this.  While  accepting  the  view  that  uric 
acid  is  the  peculiar  irritant,  I  venture  to  maintain  that  it  may 
work  its  varied  evils  without  in  every  instance  or  in  every  tissue 
giving  token  of  its  presence.  Many  of  the  difficulties  in  dia- 
gnosis, especially  in  differential  diagnosis  between  gouty  and  other 
forms  of  arthritis,  are  explained  by  admission  of  this  view.  To 
clear  the  ground  at  once,  I  would  add  that  I  distinctly  claim 
another  field  of  pathological  process  for  the  disorder  known  as 


1 6  PATHOGENY  OF  GOUT. 

chronic  rheumatic  or  rheumatoid  arthritis,  often  miscalled  (as  I 
think)  "  rheumatic  gout." 

All  that  it  is  proposed  to  treat  of  in  this  volume  relates  to 
true  and  unequivocal  gout,  as  distinguished  from  all  other  forms 
of  disease  which  affect  and  disable  joints.  Articular  gout  is  only 
a  variety"  of  gout,  the  best-marked  forms  of  which  constitute  the 
extreme  outcome  of  the  malady.  Unlike  other  forms  of  arthri- 
tis, in  which  disorder  is  mainly  or  altogether  confined  to  the 
structures  of  joints,  gouty  arthritis  is  only  a  part  of  a  widespread 
disease  affecting  variously  many  other  parts  of  the  body. 

It  is  this  character  which  has  led  to  the  application  of  the 
term  protean  to  gouty  manifestations, — a  term  not,  perhaps,  inap- 
propriate, but  one  which  has  no  doubt  sheltered  much  hasty  and 
erroneous  diagnosis.1  As  will  be  shown  later,  many  troubles 
may  occur  in  a  gouty  person  which  are  not  truly  gouty  ;  and 
certainly  many  such  occur  in  non-gouty  persons  which  are 
wrongly  attributed  to  gout,  albeit,  in  a  truly  gouty  individual, 
any  disturbance  of  the  balance  of  health  is  apt  to  be  modified 
specially  by  the  diathetic  habit  of  body.  Hence,  I  cannot  accept 
Ebstein's  dictum  that  "  we  must  seek  the  causes  of  gout  in  the 
place  where  uric  acid  is  formed." 

Before  proceeding  to  discuss  the  specific  relations  of  uric  acid 
to  gout,  as  commonly  recognized,  it  will  be  well  to  endeavour 
to  gain  as  large  and  comprehensive  a  view  of  the  entire  chain  of 
morbid  events  as  possible.  In  the  first  place,  we  have  to  face  the 
fact,  that  although  the  disorder  is  very  widely  spread,  it  is  not 
universal.  As  is  the  case  in  respect  of  rheumatism,  not  every 
one  is  or  can  become  rheumatic ;  so,  I  believe,  not  every  one  is 
or  can  become  gouty. 

Rheumatic  proclivity  is,  however,  greater  and  more  widely 
spread  than  gouty  proclivity.  Nothing  is  better  established  in 
the  nature  of  gout  than  its  hereditary  transmission.  Where  in 
any  community  there  is  most  gout,  there  has  probably  been  much 
gout  in  the  ancestry.  It  is  also  believed  that  the  disease  may  be 
induced  or  newly  acquired,  or,  at  any  rate,  so  far  as  careful 
inquiry  allows  past  family  history  to  be  invoked,  the  disease 
occurs  in  persons  who  can  trace  no  overt  inheritance  of  the 
tendency.  Without  doubt,  one  is  on  difficult  ground  here,  for 
none  so  well  know  the  fallacies  surrounding  inquiries  into  family 
history  as  those  who  have  been  at  the  pains  honestly  to  try  and 
learn  it.      In   the  case  of  gout,   however,  we  may  be  the  more 

1  "  Almost  every  sj'mptom,  from  an  eruption  on  the  skin  to  threatening  apoplexy, 
may  be  gout." — Herbert  Mayo,  F.R.S.,  Philosophy  of  Living,  p.  25,  1837. 


BASIC   ARTHRITIC    DIATHESIS.  I  7 

confident,  since  any  marked  expression  of  it,  if  ascertained  by  a 
skilled  inquirer,  is  less  apt  to  be  misunderstood  than  is  the  case 
with  many  other  diseases,  and  the  field  of  observation  is  certainly 
large  enough,  at  all  events  in  this  country. 

Other  difficulties  arise,  too,  in  working  out  this  part  of  the  great 
problem  of  gout.  Even  true  gout  does  not  always  "  breed  true," 
and  transformations  and  comminglings  of  different  morbid  states 
are  certainly  handed  down  in  the  process  of  transmission  to 
offspring.  All  this  must  be  acknowledged  and  allowed  for.  The 
whole  matter  is,  in  truth,  one  of  exceeding  difficulty,  but  for  that 
reason,  among  others,  it  is  worth  the  attempt  to  unravel  it  reason- 
ably and  with  an  open  mind.  The  view  set  forth  by  several 
distinguished  observers,  amongst  whom  I  will  mention  Laycock, 
Charcot,  and  Hutchinson,  respecting  a  basic  diathetic  habit  of 
body  called  arthritic,  has  well  commended  itself  to  my  mind. 

Not  to  enter  upon  the  large  question  of  the  several  diathetic 
or  constitutional  habits  which  may  be  observed  in  the  human 
race,  which  would  be  foreign  to  the  scope  of  this  treatise,  I  would 
express  my  belief  in  the  existence  of  such  distinct  diatheses, 
regarding  these  views  as  being  extremely  helpful  to  the  practising 
physician  in  the  present  state  of  our  knowledge,'  as  affording 
means  for  securing  further  light  and  certainty  in  studying  the 
nature  of  diseases,  and  also  much  aid  in  the  recognition  of  the 
best  means  for  averting  the  evil  tendencies  of  such  states. 

This  study  does  not  present  attractions  to  all  clinical  observers. 
Some  despise  it,  and  many,  not  having  been  trained  in  this  mode 
of  thought  and  observation,  discard  its  teachings,  and  prefer  to 
come  face  to  face  with  each  case  of  disease  as  it  presents  itself, 
and  to  deal  with  it  simply  on  what  are  called  general  principles. 
For  myself,  I  may  state  that  I  count  myself  happy  to  have  been 
trained  for  some  time  under  Laycock  to  pay  the  fullest  regard  to 
such  indications  as  have  been  laid  down  by  the  best  observers  in 
this  study,  and  I  can  affirm  that  I  daily  draw  help  and  gain 
insight  by  the  practice  of  his  principles.  With  due  care,  and 
subject  to  the  correction  of  other  methods,  great  assistance  is 
secured  from  the  physiognomical  method  of  diagnosis.  I  am  far 
from  asserting  that  this  line  of  investigation  is  absolutely  indis' 
pensable,  because  precision  in  it  is  not  to  be  gained  without  great 
pains,  and  excellence  in  it  is  perhaps  not  attainable  by  many  ;  but 
I  would  strongly  urge  its  practice,  and,  where  possible,  the  regular 
demonstration  of  it  to  students  in  addition  to  the  usual  clinical 
methods. 

I  believe  that  there  is  a  basic  arthritic  stock,  or  diathetic  habit 

B 


15  PATHOGEN Y    OF    GOUT. 

of  body,  from  which  arise,  as  branches,  two  main  and  distinct 
classes  of  disorder,  commonly  recognised  as  gout  and  rheuma- 
tism. This  was  Pidoux's  theory,  it  is  accepted  by  Charcot  and 
Hutchinson,  and  I  think  it  a  good  one  to  work  with  in  prosecut- 
ing research  into  the  nature  of  the  two  disorders  referred  to.1 
This  nosological  position  entails  indirect  relation  between  all 
forms  of  rheumatism  and  gout.  Arthritically- disposed  individuals 
are  peculiarly  vulnerable,  and  thus  sensitive  to  chauges  of  tem- 
perature, soil,  and  climate.  They  manifest  this  for  the  most  part 
by  trophic  changes  in  the  joints  and  other  structurally  allied 
tissues. 

Heredity  is  a  strongly-marked  feature  of  the  arthritic  diathesis, 
and  hence  gouty  or  rheumatic  affections  may  supervene  in  the 
descendants  of  either  gouty  or  rheumatic  persons.  The  nervous 
system  is  plainly  involved  in  this  diathesis. 

It  is  on  lines  such  as  these  that  I  venture  to  propound  the 
view  which  best  commends  itself  to  my  mind  in  respect  of  the 
pathogeny  of  gout.  It  is,  I  hold,  in  individuals  who  either  in- 
herit or  acquire  such  peculiarities  of  tissue-potentiality  that  we 
must  look  for  the  development,  in  one  direction,  of  gout,  and  in 
the  other  of  what  we  recognize  as  rheumatism.  The  specific 
characters  of  gout  are  only,  I  believe,  induced  in  those  individuals 
who  are  thus  diathetically  predisposed.  I  do  not  believe,  as  has 
been  alleged,  that  this  arthritic  habit  of  body  is  universal. 

In  1880  I  published  an  essay2  in  which  I  put  forward  a  plea 
for  the  neurotic  theory  of  gout.  The  following  propositions  ex- 
pressed the  views  I  held  at  that  time  : — 

First,  I  urged  that  the  diseased  conditions  which  are  recognized 
as  of  unequivocally  gouty  nature  are  primarily  dependent  upon  a 
functional  disorder  of  a  definite  tract  of  the  nervous  system,  and 
that  thus  gout  is  a  primary  neurosis. 

Secondly,  That  there  is  much  in  the  nature  of  the  malady  itself, 
and  much  evidence  forthcoming  by  way  of  analogy,  to  warrant 
the  conjecture  that  the  portion  of  the  nervous  system  specially 
involved  is  situate  in  some  part  of  the  medulla  oblongata,  where, 
possibly,  may  be  placed  a  trophic  centre  for  the  joints. 

Thirdly,  That  the  gouty  neurosis  may,  like  others,  be  acquired, 
intensified,  and  transmitted ;  also,  that  it  may  be  modified  variously, 
and  commingled  with  other  neuroses ;  that  it  may  suffer  meta- 
morphic  transformations,  or  be  altogether  repressed. 

1  My  friend  M.  Lancereaux  attributes  this  view  to  Fereol. 

a  Brain,  April  1880.     Translated  into  French  by  Dr.  Sordes,  with  introduction 
by  Prof.  Ball.     Paris,  1884. 


AUTHORS    VIEW'S.  19 

Fourthly,  That  this  diathetic  neurosis  imposes  its  type  upon 
the  affected  individual  in  definite  nutritional  modes,  affecting  the 
assimilating  and  excreting  powers,  exhibiting  marked  peculiarities 
in  nervous  impressibility,  and  determining,  in  more  or  less  degree, 
a  physiognomy  of  the  gouty. 

Fifthly,  That  a  large  part  of  the  phenomena  known  as  gouty 
are  due  to  perverted  relations  of  uric  acid  and  sodium  salts  in  the 
economy,  resulting  from  the  morbid  peculiarities  mentioned  under 
the  last  head.  Thus,  there  is  excess  of  urate  of  soda  in  the  blood 
before  and  during  gouty  explosive  manifestation,  and  there  is 
determination  (by  nervous  influence,  in  all  probability)  either  of 
this  salt  to  the  affected  part  (G-arrod 1),  or  there  is  a  too  free  for- 
mation of  it  at  these  inflammatory  points,  whence  it  is  deposited 
locally,  and  also  set  free  into  the  circulation  (Orel). 

The  renal  excretory  power  for  uric  acid  appears  to  be  temporarily 
inhibited  as  part  of  the  process  of  gouty  paroxysm.  This  measure 
of  renal  inadequacy  would  appear  to  prevail  in  varying  degree  as 
a  part  of  the  specific  neurosal  disorder.  In  chronic  gout,  when 
structural  disease  has  occurred,  either  tubal,  with  deposition  of 
urate  of  soda,  or  interstitial,  with  shrinking  of  the  organs,  the 
renal  inadequacy  may  admit  of  more  mechanical  explanation. 

Sixthly,  That  in  primary,  or  inherited,  gout,  the  toxeemia  is 
dependent  on  the  gouty  neurosis ;  is  the  outcome,  in  whatever 
degree,  of  it,  and  is  therefore  a  secondary  manifestation. 

Seventhly,  That  in  what  I  term  secondary  or  acquired  gout, 
the  toxasmia  is  directly  induced  by  such  habits  as  overload  the 
digestive  and  excretory  organs,  and  constantly  prevent  complete 
secondary  disposal  of  nutritional  elements  of  food  ;  that  if,  together 
with  such  toxgemia,  distinctly  depressing  and  exhausting  agencies, 
affecting  the  nervous  system,  come  into  operation,  the  special 
neurotic  manifestations  of  the  gouty  diathesis  will  occur,  and 
be  impressed  more  or  less  deeply  upon  the  individual  and  his 
offspring. 

Eighthly,  That  this  theory  of  gout,  better  than  any  other, 
correlates  all  the  known  factors  concerned  in  the  production  of 
the  varied  symptoms  of  the  malady ;  and  while  it  displaces  its 
humoral  pathology  from  the  pre-eminence  it  has  so  long  occupied, 
it  takes  full  cognizance  of  it,  and  seeks  to  place  it  in  a  clearer 
relation  to  the  phenomena  of  the  disease. 

Ninthly,  That  if  it  be  desirable  to  refer  various  maladies  to 
their  distinct  place  in  pathology,  without  reference  merely  to  their 
chemistry,  histology,  or  neurology,  the  affection  known  as  gout 

1  Op.  cit. 


2  0  PATHOGENY   OF    GOUT. 

may  perhaps  most  correctly  be  relegated,  along  with  some  others, 
to  a  class  of  diseases  which  may  be  termed  neuro-humoral. 

On  reviewing  these  several  propositions,  I  am,  at  this  distance 
of  time,  disposed  to  be  less  dogmatic  respecting  some  of  them. 
I  stand  firmly  by  the  position  that  gout  owns  a  nervous  as  well 
as  a  humoral  pathogeny.  I  am  not  now  so  strongly  disposed  to 
insist  on  that  part  of  the  theory  which  tended  to  localize  defi- 
nitely the  actual  centre  of  disturbance  in  a  limited  portion  of  the 
cerebro-spinal  axis.  Nor  am  I  prepared  to  shift  my  ground, 
and  claim  any  other  definite  tract  of  the  nervous  mass  as  the 
affected  and  unstable  centre.  I  must  freely  admit  my  inability 
to  do  so,  and  would  express  myself  more  cautiously  in  deference 
to  the  opinion  of  the  eminent  Parisian  professor  who  did  me  the 
honour  to  criticize  my  theory.  He  reproached  me  for  seeking  to 
localize  "  at  too  limited  a  point  the  primordial  lesions  of  a  malady 
essentially  general,  one  which  is,  and  always  will  be,  typical  of 
one  of  the  best-marked  of  all  diathetic  conditions."  While,  how- 
ever, ceasing  to  insist  on  this  part  of  my  theory,  I  still  look 
kindly  upon  it,  because  many  of  the  features  of  arthritic  diseases 
afford  support  to  it,  and  none  can  doubt  that  the  medulla  oblon- 
gata consists  of  series  of  centres,  some  amongst  them  possess- 
ing intimate  relations  to  the  most  distant  and  varied  organs  and 
structures  of  the  body. 

I  think  it  not  only  helpful,  but  absolutely  essential,  to  add  to 
the  purely  humoral  views  which  have  chiefly  prevailed  respecting 
the  nature  of  gout  a  conception  of  the  presiding  nervous  element. 
In  accepting  this,  we  greatly  enlarge  our  point  of  view,  and 
explain  some  of  the  most  difficult  points  which  have  hitherto  per- 
plexed careful  inquirers.  For  my  part,  I  cannot  dissever  the  two 
ideas,  and,  hence,  I  affirm  that  gout  is  a  neuro-humoral  disease.1 

It  is,  without  doubt,  the  cas9  that,  hitherto,  no  theory  has 
been  set  forth  which  appears  to  embrace  all  the  multiform  pheno- 
mena of  gouty  disease.  The  greatest  advance  of  modern  research 
has  been  to  establish  the  certainty  of  some  special  relation  to  it, 
in  the  greater  number  of  instances,  of  uric  acid,  and  so  far  there 
is  clear  warrant  for  retaining  a  measure  of  humoral  pathology  in 
our  conception  of  the  malady. 

I  propose  to  discuss,  first,  the  arguments  which  lend  support 
to  the  view  that  the  nervous  system  is  largely  involved  in  gouty 
pathogeny ;  and  in  doing  so,  I  shall  have  to  refer  to  many  points 
which  must  later  on  engage  our  attention  more  in  detail. 

1  In  respect  of  rheumatism,  I  am  prepared  to  affirm  the  same,  thus  explaining  the 
manifestations  of  that  branch  of  the  basic  arthritic  diathesis. 


GOUT    A    NEUROHUMORAL    DISORDER.  2  1 

Secondly,  I  shall  treat  of  the  pathogenetic  relation  which  uric 
acid  or  its  salts  bear  to  gout. 

The  best  approach  to  the  line  of  argument  I  purpose  to  take 
up  in  the  first  place  will  manifestly  be  to  review  the  special 
characters  of  neuroses  in  general,  and  then  to  examine,  coinci- 
dently,  how  far  the  well-ascertained  features  of  gout  conform  to 
such  characters. 

Before  proceeding  to  this  analysis,  I  would  first  assert  that 
gout  is  something  beyond  the  resultant  effects  of  aberrant  relations 
of  uric  acid  ;  that  it  consists  in  something  more  than  a  perversion 
of  animal  chemistry ;  that  it  is  not  to  be  explained  as  a  mere 
outcome  of  gastric  or  hepatic  distemper ;  and  that  it  is  not 
the  appanage  only  of  the  middle-aged  or  elderly  high-liver  and 
intemperate  drinker,  because,  as  is  well  known,  it  affects  also, 
sometimes  in  early  life,  the  high-thinker  and  the  laborious  bread- 
winner. Without  doubt,  while  accepting  all  (and  that  is  much) 
that  it  is  good  for,  one  is  impelled  to  look  beyond  what  may  be 
termed  the  chemical  pathogeny  of  gout.  The  researches  into  the 
nature  and  functions  of  the  nervous  system,  as  carried  out  during 
the  past  quarter  of  this  century,  come  to  our  aid  at  this  stage  of 
our  inquiry,  and,  amongst  these,  we  have  learned  two  main  and 
important  points  respecting  the  neuroses  in  general.  The  first  is, 
that  they  may  be  primary  or  central,  and  the  other  is,  that  they 
may  be  secondary  or  induced.  In  other  words,  it  may  be  averred 
that  a  neurosis  is  implanted,  or  a  tendency  to  it  established,  and 
this  shall  be  handed  down,  hereditarily  passed  on,  and,  thus,  a 
diathetic  tendency  be  formed ;  or,  owing  to  some  toxaemic  con- 
dition or  blood-degeneration,  a  secondary  or  induced  neurosis  may 
be  established. 

It  is  on  this  basis  that  I  shall  endeavour  to  establish  that 
part  of  the  pathogenic  theory  of  gout  which  relates  to  nervous 
influence. 

Representing  special  conditions,  or  rather  special  morbid  modes 
of  evolution,  of  nerve-force,  neuroses  are  implanted  in  the  indi- 
vidual as  a  part  of  his  intimate  nature.  They  belong  to  the 
individual,  and  are  characteristic  of  him  in  the  same  degree  that 
are  his  features  and  other  physiognomical  traits.  An  implanted 
neurosis  is,  as  it  were,  the  representative  of  a  morbid  physiog- 
nomy for  the  cerebro-spinal  axis.  A  neurosis,  then,  is  a  peculiar 
disposition  or  tendency  on  the  part  of  the  nervous  system,  or 
some  definite  tract  of  it,  towards  morbid  evolution  or  manifesta- 
tion of  nerve-functions.  It  does  not  necessitate  the  existence  of 
any  coarse  disease,  directly  obvious  to  the  eye,  but  it  is  a  more 


2  2  PATHOGENY    OF    GOUT. 

or  less  abiding  condition,  ready  to  come  into  action  upon  suitable 
provocation. 

It  is  specially  characteristic  of  neuroses  that,  being  thus 
primarily  impressed  upon  an  individual,  they  tend  to  be  trans- 
mitted by  heredity.  It  has  been  alleged  that  the  female  sex  is 
more  neurotically  disposed  than  the  male ;  but  facts  do  not  sup- 
port this  opinion  thus  broadly  put  forth.  Certain  neuroses  appear 
to  prevail  with  greater  frequency  in  males,  and  others  in  females  ; 
and  not  only  so,  but  in  the  case  of  those  that  are  common  to  both 
sexes,  the  manifestation  occurs  at  different  epochs  of  life. 

Thus,  some  outbreaks  of  neurotic  disorders  are  seen  to  occur 
at  the  several  septennial  climacteric  periods,  at  the  times  of 
dentition,  puberty,  and  often  at  the  grand  climacteric.  In  this 
manner  an  element  of  distinct  periodicity  attaches  to  neuroses  in 
general. 

Further,  a  most  marked  feature  in  all  neurotic  affections  is  that 
of  paroxysmal  tendency.  Thus,  there  is  the  abiding  element, 
with  proclivity  to  recurring  outbreak. 

Again,  it  is  certainly  known  that  a  law  of  alternation  or  sub- 
stitution prevails  in  neuroses,  and  thus  we  meet  with  certain 
neurotic  affections  in  the  parent  or  ancestors,  and  with  others 
in  the  collateral  relations  or  descendants.  We  thus  have  to 
deal  with  distinct  types  of  nervous  impression.  These  abiding 
conditions  are  more  or  less  prone  to  be  excited  into  activity 
according  to  various  circumstances. 

It  is  not  difficult  to  understand  the  course  pursued  by  a  neurotic 
taint,  once  laid  down  or  impressed ;  but  it  is  not  so  easy  to  con- 
ceive the  original  implanting  of  such  a  morbid  functional  tendency. 
The  mischief,  however,  is  constantly  originating  in  individuals, 
and  as  constantly  undergoing  further  development,  modification, 
or  even  repression. 

Excessive  activity  of  the  nervous  system,  or  of  any  part  of 
it,  as  Laycock  has  shown,  becomes  a  highly-disposing  cause 
of  the  neuroses.  Habitual  or  prolonged  excess  develops  here- 
ditary tendency.  Undue  mental  labour,  gluttony,  alcoholic  in- 
temperance, debauchery,  and  other  indulged  evil  propensities  in 
the  parent,  come  to  be  developed  into  definite  neurotic  taint  and 
tendency  in  the  offspring.  Particular  examples  of  this  are  not  far 
to  seek,  and  amongst  them  comes  out  the  disorder  so  widely  and 
variously  manifested  as  gout.  According  to  this  view,  for  which 
I  plead,  gout  appears  as  a  diathetic  neurosis,  and  a  link  in  the 
long  chain  of  its  phenomena,  so  long  missing,  is  now  forthcoming. 

I  have  already  stated  that  there  is  clear  warrant  for  retaining, 


GOUT    A    NEUROHUMORAL    DISORDER.  23 

as  'part  of  the  'pathology  of  gont,  a  humoral  hypothesis,  and  it 
may  perhaps  be  applied  and  relegated  to  its  proper  place,  as 
follows.  Granting  that  gout  in  any  individual  is  the  outcome  of 
a  central  neurotic  taint  ("  primordial  vice  of  nutrition  "),  we  have 
the  ordinary  manifestations  of  it  more  or  less  severe.  This  we 
may  term  primary  or  central  gout.  The  tendency  may  be  trans- 
mitted or  modified,  or,  conceivably,  may  be  allowed  to  die  out. 

In  another  individual,  gout  may  "  grow  up  "  where  previously 
there  was  no  neurotic  taint  or  tendency.  A  patient  is  commonly 
said  to  earn  his  gout  by  high-living  and  over-indulgence  of  appe- 
tites. In  this  instance  a  morbid  blood-state  is  induced,  and 
excess  of  uric  acid  is  generated. 

But  is  this  all  ?  Is  this  enough  to  explain  all  the  phenomena 
which  we  recognize  clinically  in  gouty  disease  ?  I  believe  not. 
We  are  compelled  at  this  point  to  widen  our  view,  and  are  driven, 
perforce,  to  invoke  the  operations  of  the  nervous  system.  Having 
arrived  thus  far  at  nothing  beyond  a  special  toxeemia,  we  must 
drop  humoral  pathology,  and  seek  for  the  effects  of  the  blood- 
dyscrasia  upon  the  nerve-centres.  And  we  have  full  warrant  for 
this  course  in  contemplating  the  analogy  of  other  toxagmic  states, 
together  with  their  effects  upon  the  nervous  system.  The  nutri- 
tion of  this  system  is  plainly  affected  by  morbid  blood-conditions, 
and  thus  expression  is  given  to  such  poisoning  in  the  form  of 
convulsion  and  other  nervous  symptoms. 

I  venture,  then,  to  suggest  that  a  secondary  affection  of  some 
nerve-centre  occurs  as  a  consequence  of  the  altered  blood  state 
ab  intra,  and  that  thus  the  order  and  particular  process  of  the 
gouty  attack  is  evolved.  This  we  may  term  secondary  or  acquired 
gout.  A  diathetic  neurosis  is  thus  impressed  upon  the  individual,1 
and  we  witness  the  results  of  a  vicious  circle  of  events  in  the 
economy. 

It  is  certainly  a  matter  of  much  interest  to  study  side  by  side 
with  gouty  processes  the  several  joint-affections  or  arthropathies 
which  have  come  to  be  regarded  of  late  as  of  distinctly  spinal  or 
otherwise  nervous  origin.  It  seems  impossible  to  separate  gouty 
arthritis  from  this  connection.  And  if  it  be  conceded  that  this 
particular  form,  which  is  but  one  of  many  others,  is  truly  and 
directly  dependent  upon  nerve-influence,  the  greatest  part  of  the 
difficulty  in   establishing  a  neurotic  theory  of  gout   is   forthwith 

1  The  frequency  and  severity  of  gout  in  England  is  explicable  on  the  view  of  the 
impressed  neurosis.  The  habits  leading  to  gout — high-living,  intemperance  in  strong 
drinks  (malt  liquors  and  wines),  along  with  much  mental  energy — have  certainly  pre- 
vailed more,  and  amongst  larger  classes,  in  England  than  in  either  Scotland  or 
Ireland. 


24  PATHOGENY    OF    GOUT. 

removed.  I  suppose  no  greater  obstacle  has  stood  in  the  way  of 
the  acceptance  more  generally  of  a  nervous  theory  of  this  malady 
than  the  impossibility  hitherto  of  connecting  arthritic  disposi- 
tion with  any  form  of  neurosis.  So  many  of  the  other,  and  less 
obvious,  manifestations  of  gout  are  plainly  dependent  on  nervous 
influence,  that  the  whole  phenomena  now  appear  to  fall  more 
naturally  into  their  places.1 

It  is,  however,  only  right  to  mention  here  that  thoughtful 
physicians  have  long  ere  now  conceived  the  special  action  of 
nerve-influence  on  joints,  and  of  arthritic  affection  on  nerve- 
centre."  The  relation  sometimes  existing  between  rheumatic 
fever  and  chorea  is  an  example  in  point,  as  Dr.  Liveing  has 
shown. 

Much  light  has  been  thrown  of  late  upon  spinal  arthropathies 
by  the  researches  of  Charcot,  Ball,  Weir  Mitchell,  and  of  Dr. 
Ord.  The  latter  has  contended  for  a  more  scientific  revision 
of  our  present  views  upon  the  pathology  of  chronic  rheumatic 
arthritis.  His  views  are  not  only  eminently  ingenious,  but  they 
accord  remarkably  with  well-observed  clinical  facts,  not  hitherto 
correlated. 

As  Sir  James  Paget  has  remarked,  the  changes  in  the  nerve- 
centres,  which  determine  the  locality  of  the  gouty  process,  are  a 
part  of  the  pathology  of  gout  which  is  not  yet  clinical.  They 
are,  therefore,  no  more  than  speculative  at  present,  but  we  gain 
much  from  the  prosecution  of  an  inquiry  in  this  direction. 

With  respect  to  the  particular  locality  affected  in  the  arthro- 
pathy of  locomotor  ataxia,  there  is  some  discrepancy  of  opinion. 
Charcot  has  declared  for  implication  of  the  anterior  cornua  of 
the  spinal  chord.  Dr.  Buzzard,  however,  has  not  confirmed 
this  opinion,  and,  guided  by  the  noteworthy  frequent  associa- 
tion of  gastric  crises  with  joint-affections  in  this  malady,  as 
previously  observed  by  Dr.  Ball,3  has  suggested  a  sclerosing 
lesion,  involving  the  roots  of  the  vagus  in  the  medulla  oblongata, 
in  close  relation  to  some  trophic  centre  that  may  be  localized 
there,  presiding  over  the  osseous  and  articular  systems.  And 
he  further  indicates  the  bond  that  may  thus  exist  between  impli- 
cation of  joints  and  such  metastasis  as  may  occur  to  the  heart 
in  rheumatic  fever :  also  the  occurrence  of  hyperpyrexia,  which 
is  sometimes  present  in  such  cases.     We  have  yet  to  seek  for 

1  "The  preference  which  tophus  shows  for  the  joints  is  a  remarkable  fact,  which 
we  cannot  explain,  and  which  presents  a  great  subject  of  reflection  to  physicians." — • 
Trousseau. 

2  Liveing,  op.  cit.,  p.  247. 

a  Med.  Times  and  Gazette,  vol.  ii.  (1868);  vol.  ii.  (1869),  p.  498. 


AUTHOR  8    VIEWS.  25 

this  hypothetical  nutrient  centre  for  joints,  but  in  the  meantime 
we  are  fairly  warranted  in  widening  our  view,  and  in  directing 
attention  to  the  high  significance  of  predicating  such  a  trophic 
centre. 

"  Discovery  by  true  analogies  is  always  progressive,  .  .  .  one 
analogy  leads  on  to  another  investigation  and  arrangement  of 
phenomena,  and  another  analogy."  1 

It  remains  now  to  be  shown,  more  in  detail,  how  the  pheno- 
mena of  gout  conform  to  the  recognized  manifestations  of  the 
neuroses  in  general. 

It  can  be  shown,  I  believe,  that  the  plea  for  the  neurotic  ele- 
ment in  true  gout  is  not  difficult  to  establish. 

First,  there  is  to  be  considered  the  marked  tendency  of  gout 
to  be  hereditarily  transmitted.  This  is  notorious.  The  disorder 
may  pass  from  either  parent,  and  may  be  mingled  with  other 
taints  and  tendencies  passed  on  from  the  progenitors.2  The 
outbreak  may  occur  in  slight  or  in  graver  degrees,  and  may 
be  deferred,  overtly,  till  even  the  thirteenth  climacteric  period. 
Thus,  the  first  plain  attacks  of  gout  may  not  appear  till  the 
patient  is  sixty  or  over  ninety  years  of  age.  In  all  such  cases, 
however,  I  am  convinced  that  many  minor  tokens  of  the  disorder 
have  been  overlooked  in  previous  years,  all  of  which  are  suffi- 
ciently obvious  to  the  trained  clinical  eye.  As  a  rule,  the  mani- 
festations are  prone  to  occur  at  definite  ages  in  each  sex,  most 
commonly  in  the  fourth  decade  in  men,  and  in  the  fifth  in 
women.  My  own  experience  appears  to  show  that  gout  is  fre- 
quent in  men  early  in  the  third  decade. 

Certain  peculiarities  attending  gouty  transmission  are  deserving 
of  study.  Mr.  Hutchinson  has  called  attention  to  one  of  these  in 
a  suggestive  lecture.3  He  expresses  his  belief  that  what  is  trans- 
mitted is  not  the  active  gouty  dyscrasia  itself,  but  rather  a  sus 
ceptibility  to  the  influence  of  certain  exciting  causes,  together 
with  some  peculiarly  disordered  condition  of  the  assimilating  and 
excretory  viscera,  which  renders  them  unable  to  deal  with  parti- 
cular articles  of  food.  Now,  this  special  susceptibility  to  definite 
exciting  factors  is  neither  more  nor  less  than  a  nervous  peculiarity, 

1  Laycock,  op.  cit.,  p.  190. 
"  If   the  countenance,  the  outside,  is  hereditary,  why  not  the  inside  ?  "—Letter 
to  Dr.  Cadogan,  occasioned  by  his  Dissertation  on  the  Gout,   &c,    London,    1771. 
(Cadogan  tried  to  show  that  gout  was  not  hereditary.) 

" Hereditariness  of  gout  is  like  the  hereditariness  of  a  Roman  nose;  it  is  part 
of  a  family  likeness  ;  the  particular  chemical  type,  the  particular  mode  and  rate  of 
the  chemical  change  of  tissue,  passes  from  father  to  son  as  the  shape  of  features 
passes." — Sir  John  Simon,  Path.  Soc.  Trans.,  vol.  xxvii.  p.  419. 

3  Medical  Times  and  Gazette,  vol.  i.  p.  543,  1876. 


26  PATHOGENY    OF    GOUT. 

of  which  the  chief  character  is  its  liability  to  break  away  in  cer- 
tain morbid  directions — its  instability,  in  short.  This  is,  I  submit, 
the  gouty  neurosis.  Mr.  Hutchinson  further  believes  that  gout 
is  wont  to  show  itself  with  greater  frequency  and  in  more  marked 
form  in  the  younger  than  in  the  older  members  of  a  gouty 
family,  the  diathesis  strengthening  in  the  parent  with  advanc- 
ing years.  I  can  confirm  this  observation.1  Resemblance  to 
the  gouty  parent  has  been  specially  recognized  in  those  of  the 
offspring  most  distinctly  affected.2  In  other  members  of  the  family 
the  tokens  of  gout  may  be  present,  but  less  marked.  These  facts 
are,  of  course,  in  accordance  with  ordinary  laws  of  hereditary 
transmission.  Dr.  Wickham  Legg  has  called  attention  to  the 
fact  that  gout,  like  haemophilia,  pseudo-hypertrophic  paralysis  of 
Duchenne,  and  some  other  affections,  is  not  unfrequently  found  to 
be  transmitted  by  the  female  line,  although  especially  manifested 
in  males,  the  mothers  themselves  being  unaffected  by  readily 
recognized  gout. 

A  noteworthy  feature  in  gouty  ailments  is  their  sudden  super- 
vention. As  in  epilepsy,  not  uncommonly,  the  patient  often  feels 
remarkably  well,  and  realises  his  sense  of  Men  Stre  before  the 
outbreak  suddenly  takes  place.  This  euphoria,  or  delusive  cor- 
poreal satisfaction,  is  itself  a  nervous  derangement.  Explosiveness 
is  a  distinct  feature  in  several  of  the  neuroses,  and  attaches  to 
such  ailments  as  angina  pectoris,  asthma,  epilepsy,  and  various 
neuralgias. 

The  time  of  the  occurrence  of  the  attack  is  also  strongly 
marked.  The  majority  of  the  outbreaks  take  place  in  the  early 
morning.  This  is  true  both  of  grave  and  classical  cases,  and  also 
of  many  of  the  minor  forms  of  gouty  trouble.  The  same  thing 
is  met  with  in  asthma,  neuralgia,  and  in  epilepsy.  The  pyrexia 
proper  to  acute  gout  is  paroxysmal,  with  remissions,  and  the  pain 
of  gout  is  likewise  paroxysmal.  One  is  here  reminded  of  the 
influence  of  marsh-poison  upon  the  nervous  centres. 

This  paroxysmal,  no  less  than  the  periodic,  element  in  gout, 
stamps  a  nervous  character  upon  the  malady,  and  binds  it  in 
alliance  with  other  neuroses.3 

An  important  connection  of  the  same  kind  is  seen  in  the 
unquestionable  commingling  of  gout  with  other  well-recognized 
neuroses.  Thus,  hemicrania  is  sometimes  distinctly  a  manifes- 
tation of  gout  in  both  sexes,  and  may  be  the  form   of  neurosis 

1  Cases  illustrating  this  are  given  by  Sir  Spencer  Wells,  Bart.,  op.  cit.,  p.  18 

2  Op.  cit.,  Sir  Henry  Holland,  Bart.,  M.D.,  F.R.S.,  3rd  edit.,  1855,  p.  29. 

3  Vide  Scudamore,  op.  cit.,  p.  152. 


AUTHORS    VIEWS.  2/ 

impressed  upon  an  individual  whose  parent  was  gouty,  or  may 
itself  alternate  with  gouty  arthritic  attacks  in  the  same  person.1 

It  is  not  far  to  seek  for  an  allied  condition  of  trophical  lesion 
in  herpes  zoster,  itself  the  outcome  of  disordered  innervation. 

The  doctrine  of  metastasis  must  next  be  considered  in  relation 
to  gout.  The  pure  humoralist  seeks  to  explain  this  clinical  fact 
upon  his  theory,  but  such,  is  manifestly  insufficient  to  account  for 
the  phenomena.  It  must  be  conceded  that  some  nervous  law 
regulates  the  occurrence  of  shitting  inflammation.  It  has  been 
supposed  to  be  due  to  reflex  influence.  Some  distinct  predispo- 
sition to  take  on  the  morbid  action  exists  in  the  part  selected, 
apparently,  by  caprice.  The  same  class  of  tissue  is  apt  to  suffer. 
Thus,  the  gouty  or  rheumatic  process  flies  from  joint  to  joint,  or, 
as  in  gouty  phlebitis,  from  vein  to  vein,  sometimes  symmetrically, 
but  not  always.  The  serous  and  fibro-serous  structures  suffer 
especially,  but  also  mucous  surfaces.  Laycock  has  shown  how 
these  several  tissues  are  related  embryologically,  and  are  thus 
prone  to  suffer  in  common  when  diathetically  impressed.2 

Localized  trophical  changes  follow  locally  acting  causes  of 
depressed  nervous  power.  Thus,  impairment  of  certain  centres 
may  lead  to  the  specific  nutritional  changes  witnessed  in  meta- 
stases, and,  thus,  the  apparent  capriciousness  is  explained  in  this 
process. 

Amongst  the  nervous  symptoms  of  gout  must  next  be  con- 
sidered the  occurrence  of  certain  sensory  perversions,  such  as 
tingling  and  numbness  of  the  fingers  and  toes,  sensations  of  heat 
in  the  palms,  thighs,  and  soles  (pargesthesia),  and  tickling  in  the 
throat.  As  pointed  out  by  Sir  James  Paget,  "gout  affects  the 
sensory  much  more  than  the  motor  elements  of  the  nervous 
system ;  "  and  he  remarks,  too,  that  the  pain  of  acute  gout  is 
seemingly  out  of  all  proportion  to  the  amount  of  inflammatory 
process  in  the  affected  part.  So,  too,  all  other  disorders,  modified 
by  gout,  seem  to  be  especially  painful ;  for  example,  cancer,  as 
pointed  out  also  by  Paget. 

Grinding  of  the  teeth  is  met  with  in  the  gouty.  Graves  first 
observed  this.3  Dr.  Donkin  has  recorded  cases  associated  with 
somnambulism,4  and  I  have  intimate  knowledge  of  two  others 
in  which  the  same  phenomena  are  manifested — the  gnashing  of 
teeth  and  somnambulism  in  a  sister,  and  the  talking  in  sleep  in 

1  Stahl,  op.  cit.,  §  xxxvi.  ;  Trousseau,  Clin.  Med.  ;  Liveing,  op.  cit.,  &c.  ;  Sir  H. 
Holland,  op.  cit.,  Relation  of  Asthma  to  Gout,  p.  36. 

2  Op.  cit.,  p.  196. 

3  Clin.  MeU,  p.  351,  edit.  1864. 

4  Brit.  Med.  Journal,  Feb.  21,  1880,  p.  279. 


2  8  PATHOGENY    OF    GOUT. 

the  brother.  The  maternal  grandfather  and  the  mother  are  dis- 
tinctly gouty.  Cramps  in  the  muscles  of  the  legs  and  priapism 
are  amongst  nocturnal  manifestations  in  the  gouty.  Of  insom- 
nia, due  to  gout,  there  is  much  to  say.  It  was  originally  noted 
by  Cullen,  and  it  conforms  remarkably  with  other  periodic  neurosal 
phenomena.1 

Gouty  neuralgia  is  largely  recognized,  and  is  known  to  be  both 
severe  and  prone  to  recur.  It  is  frequently  occipital,  and  is  met 
with  in  the  heel,  tongue,  breast,  arms,  and  more  often  in  the 
great  sciatic  nerve.  One  proof,  amongst  others,  of  the  truly 
gouty  nature  of  these  is  gained  from  the  fact  that  they  yield 
most  readily  to  anti-gouty  medication,  and  another  lies  in  the 
frequency  with  which  they  are  provoked  by  conditions  which 
elicit  other  gouty  processes. 

Amongst  the  strongest  evidences  of  gout  depending  upon 
nervous  influences  are  the  unquestionable  facts  bearing  upon  the 
induction  of  its  attacks. 

The  influence  of  many  of  the  existing  causes  of  gouty  par- 
oxysms illustrates  well  the  explosive  character  of  the  malady. 
As  Sydenham  expresses  it,  before  the  onset  of  an  attack,  "  totum 
corpus  est  podagra."  The  precipitation  of  the  seizure  sometimes 
ensues  almost  immediately  upon  the  provoking  cause.  In  a  large 
number  of  instances,  the  latter  is  of  a  nature  to  depress  nervous 
power.  Thus,  unwonted  muscular  energy,  prolonged  exercise, 
stirring  emotions,  fright,  undue  excitement,  venereal  excess,  rage, 
worry  and  vexation,  are  all  excitors  of  gouty  paroxysm.  So,  too, 
sudden  shock  to  the  body,  as  from  injuries  and  surgical  operations, 
will  evoke  gout.  Dietetic  errors  are  well  recognized  as  factors ; 
thus,  a  full  meal,  and  excess  or  mixing  of  strong  liquors,  will  act 
in  upsetting  the  equilibrium  of  a  quiescent  gouty  habit.  It  will 
be  conceded  that  many  of  the  causes  just  enumerated  are  equally 
potent  to  elicit  manifestations  of  other  neuroses,  such  as  epilepsy, 
asthma,  hemicrania,  and  angina  pectoris.  The  provoking  agency, 
however,  need  not  always  be  primarily  exhausting.  In  proof  of 
this,  the  outbreaks  of  gout  following  hydropathic  treatment,  in- 
ternally or  externally,  may  be  instanced  ;  and,  indeed,  the  causal 
element  need  only  be  such  as  shall  induce  some  change  in  the 
acquired  vital  habits. 

Thus  it  is  that  the  subjects  of  the  neuroses  hold  much  of  their 
comfort  in  life  by  following  a  very  equable  routine.  They  are 
prone  to  give  way  under  any  extraordinary  pressure. 

1    Vide  author's  paper,  St.  Barth.  Hosp.  Reports,  jam  cit.,  p.  105  ;  and  Brain,  July 
1 881. 


AUTHOR  3    VIEWS.  29 

These  considerations  explain,  in  part,  why  men  are  more  liable 
to  gout  than  women.  They  carry  on  the  world's  rough  work  ; 
are  engaged  in  more  exciting  occupations,  and  have  commonly 
the  greater  burden  of  anxiety  to  bear. 

The  more  sedentary  the  occupation,  the  more  profound  the 
mind-working,  and  the  more  intense  the  strain  of  life,  the  greater 
the  tendency  to  nervous  depression,  and  to  the  peculiar  form  of 
its  expression  in  gout.  If  to  such  habits  be  added  high-living, 
as  often  occurs  in  the  cases  of  eminent  statesmen,  lawyers,  and 
speculators,  no  link  is  wanting  in  the  chain  of  causation,  and  all 
the  elements  for  gout  are  present. 

Climatic  influence  is  important  amongst  these  agencies.  The 
dull  and  "  shifty  "  weather  and  the  cold  east  winds  of  northern 
latitudes  are  certainly  bad  for  gout.  The  nervous  depression 
ensuing  upon- months  of  sunless  skies — negation  of  light  power- 
fully lowering  nervous  tone — is  too  little  regarded  as  an  element 
of  devitalization  in  England.  The  cutaneous  eliminant  power  is 
checked,  and,  so,  aberrant  chemical  relations  are  apt  to  be  deter- 
mined in  any  parts  specially  prone  to  gouty  invasion. 

The  same  mal-determination  ensues  upon  the  suppression  of 
various  discharges,  whether  from  the  uterus,  from  haemorrhoids, 
or  other  sources. 

The  mental  condition  of  the  goutily-disposed  is  a  subject 
worthy  of  attention  in  relation  to  the  pathology  of  the  ailment. 

Hypochondriasis  has  long  been  associated  with  gouty  taint. 
It  commonly  precedes  an  outbreak,  and  disappears  subsequently. 
A  tendency  to  sighing  has  also  been  observed,  and  is  a  plain  in- 
dication of  nervous  exhaustion.  Hysteria  has  also  been  observed 
to  precede  gouty  attacks  in  women,  and  to  disappear  with  the 
onset  of  articular  symptoms.1 

Irritability  of  temper  is  a  proverbial  condition  in  the  gouty, 
and  furious  outbursts  of  this  kind  appear  to  be,  at  times,  a 
metamorphic  substitution  for  a  more  overt  and  regular  attack. 
It  is  important  to  know  that  many  of  the  minor,  but  none  the 
less  well-marked,  phases  of  gouty  paroxysm  are  in  no  degree 
arthropathic.  Much  error  in  diagnosis  has  arisen  from  taking 
no  heed  of  any  but  articular  symptoms  when  searching  for  gouty 
tokens  in  a  given  case.  These  less  classical  attacks  very  com- 
monly precede  the  onset  of  typical  ones  at  a  later  period  in  life. 
The  necessity  for  prompt  recognition  of  these  less  well-expressed 
symptoms  is  obvious,  if  good  treatment  is  to  be  applied. 

1  On  the  Relations  between  Gout  and  Hysteria,  vide  Treatise  on  the  Nervous 
Diseases  of  Women,  p.  163.     By  T.  Laycock.     1840. 


30  PATHOGENY    OF    GOUT. 

Epilepsy  has  been  known  to  disappear  on  the  supervention  of 
gout. 

Sensations  of  giddiness  and  dimness  of  vision,  not  uncommon 
in  the  gouty,  are  noteworthy  in  relation  to  nervous  symptomato- 
logy.1 So,  too,  the  disturbances  of  the  cardiac  rhythm,  and  the 
co-existent  (neurotic)  vascular  throbbings  which  are  sometimes 
met  with.  The  cardiac  irregularity  has  been  noted  to  cease 
with  the  induction  of  a  regular  attack.  Dysphagia  was  noted 
in  connection  with  gout  by  no  less  careful  an  observer  than  the 
late  Dr.  Brinton. 

A  consideration  of  the  effects  of  lead-impregnation  in  relation 
to  gout,  and  of  the  certain  liability  of  the  gouty  to  be  more 
readily  than  others  influenced  by  lead,  leads  to  the  belief  that  the 
nervous  system  is  specially  implicated  in  these  relations.  The 
fact  is,  that  the  blood  is  imperfectly  freed  from  uric  acid  in  cases 
of  lead-poisoning,  and  that  gout  is  thus  quickly  evoked.  Garrod 
has  fully  established  these  facts,  and  all  physicians  now  recognize 
them.  The  lead-influence,  clearly  through  nervous  agency,  induces 
the  measure  of  renal  inadequacy  which  is,  probably  with  correct- 
ness, acknowledged  as  a  factor  in  gout.  And  the  knowledge  that 
this  metal  is  capable  of  setting  up  special  paralysis,  epilepsy, 
coma,  and  other  cerebral  phenomena,  is  of  the  largest  interest  in 
relation  to  this  subject. 

I  now  approach  a  point  in  connection  with  the  whole  patho- 
logy of  gout  which  merits  much  consideration.  The  connection 
of  diabetes  with  gout  has  been  recognized  for  some  years. 

I  object  to  the  term  diabetes  as  applied  to  the  special  form  of 
glycosuria  associated  with  gout.  The  disorder  is  met  with  in 
certain  members  of  gouty  families,  some  having  regular  gout, 
and  others  manifesting  less  regular  gout,  or  this  alternating  with 
glycosuria.  I  believe  that  many  cases  of  temporary  glycosuria 
are  due  to  gouty  conditions.  The  fleeting  presence  of  glucose 
in  the  urine  of  many  elderly  persons  may  be  thus  explained.  It 
has  long  been  recognized  that  such  an  affection,  which,  in  many 
instances,  is  undeserving  of  the  name  diabetes  mellitus,  for  the 
simple  reason  that  there  is  no  diabetes  in  the  strict  sense  of  the 
term,  is  not  really  a  grave  one.  The  presence  of  glucose  is  found 
to  alternate  with  that  of  uric  acid.  In  the  aged  but  little  import- 
ance should  be  attached  to  the  symptom.  Charcot  testified  to 
this,  some  years  ago,  in  his  excellent  lectures  on  the  maladies  of 
old  people,  his  experience  being  gathered  at  that  fertile  school  of 

1  Trousseau,  Murchison,  Paget  op.  cit. ;  H.  Mayo,  Philosophy  of  Living,  p.  24, 
I837- 


AUTHORS    VIEWS.  3  I 

study — the  Salpetriere.  la  persons  under  forty  years  of  age, 
however,  glycosuria,  even  of  gouty  origin,  is  a  most  grave  matter, 
and  merits  the  closest  attention,  since  it  may  eventuate  in  con- 
firmed diabetes.  It  is  the  rule  to  find  that  the  quantity  of  urine 
passed  is  not  much,  if  at  all,  above  the  normal,  but  the  specific 
gravity  may  range  from  1.035  to  1. 050.  An  anti-gouty  treat- 
ment is  called  for,  for  the  glucose  may  otherwise  only  give  place 
to  uric  acid  or  increased  azoturia,  and  the  gouty  habit  has  rather 
to  be  attacked  than  the  glycosuria. 

Dr.  Lauder  Brunton  has  called  attention  to  this  class  of  cases.1 

The  alliances  of  gout  and  diabetes  are  sufficiently  intimate.  In 
both  the  doctrine  of  heredity  applies,  and  the  nervous  system  is 
involved.  The  same  habits  lead  to  each,  the  same  classes  of  per- 
son are  affected,  and  the  same  exciting  causes  are  potent  to  evoke 
both.  A  consideration  of  these  facts  naturally  leads  to  the  belief 
that  the  portions  of  the  nervous  system  involved  in  each  cannot 
be  far  apart  from  one  another.  The  medulla  oblongata,  the 
sympathetic  and  splanchnic  nerves  have  been  found  chiefly 
affected,  and  the  spinal  chord  likewise  in  some  instances.  The 
point  for  the  diabetic  puncture  in  the  medulla  is  believed  by 
physiologists  to  correspond  to  the  vaso-motor  centre  in  the  same 
structure. 

Guided  by  these  facts,  and  by  the  knowledge  that  the  glyco- 
genic function  of  the  liver  is  under  nervous  influence,  by  the 
advancing  theories  which  refer  special  arthropathies  likewise  to 
the  same  influence,  and  bearing  in  mind  Dr.  Buzzard's  views, 
previously  stated,  in  connection  with  the  gastric  crises  so  com- 
monly associated  with  the  arthritis  of  locomotor  ataxia,  I  venture 
upon  the  hypothesis  that  the  portion  of  the  nervous  system  which 
is  specially  predisposed  to  the  irregular  mode  of  action  known  as 
gout,  has  its  seat  or  centre  in  the  medulla  oblongata. 

A  point  of  difference  between  the  arthritic  affections  which  are 
now  referred  to  nervous  influence  and  those  manifested  in  gout, 
is  found  in  the  fact  that  the  latter  appears  to  have  an  elective 
affinity,  often  unilateral  at  first,  for  the  smaller  joints,  especially 
that  of  the  big  toe,  while  most  of  the  others  influence  the  larger 
ones.      Herein,  perhaps,  lies  part  of  the  specificity  of  gout. 

The  trophical  results  of  the  latter  are  often  seen  impressed 
upon  the  physiognomy,  and  upon  certain  tissues,  in  a  manner 
extremely  definite  and  characteristic. 

Thus,  are  found  the  large  head,  the  thick  hair,  with  tendency 
to  early  greyness,  the  large,  full  veins,  the  long  uvula,  the  soft, 
1  Art.  "Diabetes  Mellitus,"  Reynolds'  Syst.  of  Med.,  vol.  v.  p.  381,  1879. 


32  PATHOGENY    OF    GOUT. 

smooth  skin,  the  thickened  extremity  of  the  nose,  and  the  lineated, 
brittle  nails. 

Lastly,  I  may  add  an  argument  from  the  therapeutical  side. 

The  universally  acknowledged  specific  action  of  colchicum  in 
gout  is  known,  owing  to  Garrod's  researches,  to  be  due  to  no 
power  which  it  possesses  of  causing  elimination  of  uric  acid. 
Gouty  inflammation  is  therefore  influenced  by  it  without  reference 
to  the  secondary  aberrant  relations  of  uric  acid.  The  active 
principle  or  alkaloid  of  the  drug  colchicina  is  a  member  of  a 
nitrogenized  group  of  bodies  to  which  veratrina,  strychnia,  quinia, 
and  morphina  have  close  chemical  alliance.1  They  all  powerfully 
affect  the  nervous  system.  Colchicum  acts  very  promptly,  and 
affords  often  decided  relief  to  the  intolerable  pain  of  the  gouty 
process.  When  taken  in  health  in  small  doses,  Dr.  Meldon  and 
others  have  found  that  it  induces  a  general  glow  at  the  surface 
of  the  body,  diaphoresis,  throbbing  of  the  blood-vessels,  and  palpi- 
tation. Subsequently  there  is  reduction  in  the  force  and  fre- 
quency of  the  pulse.  Dr.  Meldon  observed  in  his  own  case  an 
invigoration  of  his  mental  energies.  In  larger  doses,  the  effects 
are  most  marked  along  the  whole  tract  supplied  by  the  vagus,  and 
thus  cardio-vascular,  gastric,  and  enteric  symptoms  ensue. 

The  peculiar  benefit  derived  from  this  drug  is  not  secured  in 
any  other  form  of  inflammation,  and  thus  it  is  plainly  specific. 
Its  cherished  action  is  doubtless  exerted  upon  the  vaso-motor 
nerves. 

The  manifestly  good  influence  of  all  agencies  which  cheerfully 
inspire  the  mental  condition  in  the  goutily  disposed,  must  not  be 
omitted  from  consideration  amongst  the  juucntia  both  of  preven- 
tion and  cure. 

It  may  be  affirmed,  in  opposition,  to  the  views  expressed  as  to 
the  neuro-pathogeny  of  gout,  that  the  disease  is  met  with  in 
persons,  and  under  conditions,  where  no  such  high-strung  state 
of  nervous  system  as  predicated  exists.  Sydenham  declared  that 
gout  rarely  attacked  fools.2  This  is  not  quite  in  accordance  with 
facts,  at  least  nowadays  ;  but  even  in  fools  the  great  trophic  pro- 
cesses of  the  body  are  dominated  by  a  nervous  mechanism.  And 
if  it  be  urged  that  such  a  conception  is  high-flown,  and  unneces- 
sary for  practical  purposes  and  treatment,  I  would  remark,  that 
the  therapeutic  art  is  daily  practised,  and  with  good  results,  by 

1  Vide  Lectures  on   Pathology  and   Therapeutics.      London,    1S67,    p.  137.      H. 
Bence  Jones,  M.D.,  F.R.S. 

2  The  same  may  be  said  in  respect  of  delirium  tremens,  which  is  most  often  met 
with  in  men  of  superior  mental  ability. 


AUTHORS    VIEWS.  33 

many  who  can  give  scant  scientific  reasons  for  their  dealings.  I 
will  humbly  venture  to  include  myself  in  this  category.  In  this 
case,  however,  I  believe  that  the  enlarged  conceptions  gained  by 
due  regard  to  the  neuro-pathogenic  element  in  gout  cannot  fail 
to  avail  us  at  the  bedside. 

I  now  proceed  to  discuss,  secondly,  the  pathogenetic  relations 
of  uric  acid  to  gout. 

Of  late  years  our  knowledge  of  the  physiology  and  intimate 
chemical  relations  of  uric  acid  has  received  important  additions. 
It  is  ascertained  to  be,  like  urea,  a  simple  derivative  of  the  dis- 
integration of  albuminous  tissues  or  of  albuminous  food-elements 
(proteids).  It  is  a  crystalline  compound,  white  in  colour  when 
pure,  consisting  of  CgH4N403.  Although  it  has  been  asserted, 
it  is  not  proved,  that  uric  acid  is  an  antecedent  of  urea  in 
the  normal  nitrogenous  metabolism  of  the  body.  It  occurs  as 
a  normal  constituent  of  the  urine,  being  excreted  to  the  extent 
of  a  little  over  eight  grains  in  twenty-four  hours,  chiefly  in 
the  form  of  sodium  biurate,  the  acid  joining  part  of  the  base  of 
the  alkaline  phosphate  of  sodium  existing  in  the  blood.  Whether 
this  conjugation  occurs  in  the  general  circulation  or  in  the  kid- 
neys, is  not  certainly  known.  A  prominent  character  of  uric 
acid  is  its  insolubility.  It  is  a  bibasic  acid,  forming  with  bases 
both  neutral  and  acid  salts  or  biurates.  Ammonium  and  sodium 
urates  are  found  in  normal  urine,  the  former  being  the  less 
soluble  of  the  two  salts.  Potassium  urate  is  more  soluble  than 
either,  and  lithium  urate  is  the  most  soluble  of  all.  Neutral 
uratic  salts  are  very  unstable.  Acid  urates  or  biurates  are  the 
most  stable  salts.  Neutral  sodium  urate  is  more  endosmotic  than 
the  biurate  sodium  salt,  and  the  latter  is  readily  formed  (and 
with  it  gouty  manifestations)  from  the  former,  if  the  blood  becomes 
from  any  cause  less  alkaline. 

Uric  acid  requires  15,000  parts  of  cold  water  and  I  800  parts 
of  hot  for  its  solution.  Alkaline  fluids  readily  dissolve  it,  also 
sodium  phosphate.  When  excreted  in  excess  in  urine,  it  is  de- 
posited variously  as  rosettes,  rhombs,  or  diamond-shaped  crystals, 
stained  by  urinary  pigments. 

The  ammonium  urate  of  the  urine  is  believed  to  be  partly 
formed  in  the  kidney.  The  sodium  salt  is  that  possessing  patho- 
logical interest  in  gout,  constituting  the  essential  ingredient  of 
tophi.  It  is  met  with  in  the  blood  of  the  gouty,  but  also  under 
other  conditions  quite  apart  from  this  disease.  It  crystallizes 
in  fine  prismatic  needles,  and  constitutes,  sometimes  with  lime 
salts,  the  bulk  of  the  gross  uratic  deposits  met  with  in  the  tissues 

c 


34  PATHOGENY  OF    GOUT. 

of  the  gouty.  These  deposits  possess  the  property  of  doubly 
refracting  light  when  examined  by  the  polariscope.  Sodium 
biurate  is  soluble  in  800  parts  of  cold  water.  Dr.  Tichborne,  of 
Dublin,  has  found  that,  at  the  temperature  of  the  body,  one  part 
of  uric  acid  is  soluble  in  1660  parts  of  water,  and  that  sodium 
biurate  is  much  more  soluble  at  the  same  temperature.1 

It  is  important  to  note  that  nowhere  in  health  is  uric  acid 
met  with  as  such.  The  presence  of  free  uric  acid  anywhere  in 
the  body,  or  in  any  secretion,  is  a  sign  of  disease.  As  is  well 
known,  in  both  the  mammalia  and  herbivora  the  quantity  ex- 
creted is  small.  In  birds,  especially  the  granivora,  and  snakes, 
the  amount  passed  is  large,  exceeding,  or  entirely  replacing, 
urea.  Together  with  urea,  the  quantity  is  increased  by  nitro- 
genous or  animal  diet,  and  diminished  by  non-nitrogenous  or 
vegetable  diet.  It  is  also  greatly  increased  during  febrile  con- 
ditions. 

Uric  acid  has  been  synthetically  produced  out  of  the  body 
by  Horbaczewski  of  Vienna,  and  by  Dr.  Latham  of  Cambridge.2 
Glycocine  and  urea  heated  together  are  found  to  yield  it.  Gly- 
cocine  never  occurs  free  in  the  body,  but  is  derived  from  glyco- 
cholic  acid,  which,  in  conjunction  with  sodium,  is  one  of  the 
natural  salts  of  the  bile.  The  liver  salts,  glyococholate  and 
taurocholate  of  sodium  (bilin),  are  decomposed  in  the  duodenum, 
splitting  up  respectively  into  cholic  acid  and  glycocine,  and 
cholic  acid  and  taurine.  The  glycocine  and  taurine  are  absorbed 
by  the  portal  vein,  while  the  cholic  acid  passes  off  by  the  in- 
testine. There  is  increasing  evidence  to  show  that  the  chief 
antecedents  of  urea  are  partly  kreatine,  a  primary  product  of 
muscular  and  other  disintegration,  and  leucine  and  tyrocine 
derived  from  the  alimentary  canal.  It  has  been  surmised  that 
both  urea  and  uric  acid  start  from  a  body  containing  some  of  its 
nitrogen  in  the  form  of  cyanogen,  and  that  urea,  as  being  more 
soluble,  is  adapted  to  the  fluid  urine  of  mammals,  while  uric 
acid  is  better  fitted  for  the  solid  urinary  excretion  of  birds  and 
reptiles. 

According  to  Dr.  Latham,  the  occurrence  of  uric  acid  in  the 
urine  is  due  to  defective  transformation  of  glycocine  into  urea. 
Glycocine  passes  unchanged  into  the  liver,  where  it  is  conjugated 
with  urea  derived  from  metabolism  of  other  amido-bodies,  leu- 
cine, tyrosine,  &c,  and  is  converted  into  hydantoin,  which  is 
readily  soluble,  and  passes  on  into  the  circulation  to    combine 

1  Lancet,  Nov.  19,  1887,  p.  1097. 
2  Croonian  Lectures,  Roy.  Coll.  Phys.,  p.  57.     London," 1 886. 


AUTHORS    VIEWS.  3  5 

in  the  kidneys  with  other  molecules  of  urea  to  form  ammonium 
urate.  A  portion  of  this,  he  thinks,  overflows  into  the  circula- 
tion, all  not  being  excreted,  and  combines  with  sodium  in  the 
blood  to  form  urate  of  sodium. 

It  has  been  proved  by  Schroeder,  in  the  case  of  birds,  that 
uric  acid  is  not  specially  produced  in  the  kidneys,  but  in  the 
tissues  generally. 

H.  Ranke  has  maintained  that  the  spleen  is  an  important 
seat  of  uric  acid-production,  and  he  was  led  to  this  belief  by 
the  fact  that  in  all  cases  of  splenic  enlargement  there  is  in- 
creased excretion  of  the  acid.  This  latter  fact  has  been  con- 
firmed in  cases  of  splenic  and  lymphatic  leuchsemia,  and  it  is 
also  found  that  this  excretion  diminishes  in  intermittent  febrile 
attacks,  and  is  subdued  by  quinine.  Deficiency  of  red  globules 
carrying  oxygen  has  been  suggested  as  a  cause  for  this.  It  may, 
therefore,  be  surmised  that  the  spleen  and  blood-glands  generally 
take  part  in  the  formation  of  uric  acid,  and  that  this  process 
is  associated  with  blood-formative  rather  than  with  blood-destroy- 
ing function.  Dr.  Haig  is  of  opinion  that  uric  acid  when  re- 
tained in  the  body  is  largely  held  back  by  the  spleen.  The  liver 
is,  however,  the  organ  in  which,  in  health,  uric  acid  is  chiefly 
formed,  and  it  is  probably  to  derangement  of  function  in  this 
gland  that  we  must  look  for  over-production  of  this  substance. 
As  already  stated,  Murchison  suggested  that  functional  disorder  of 
the  liver  not  only  caused  deficient  secretion  of  bile,  but  also  in- 
terference with  the  normal  metabolism  of  albuminous  matters,  so 
that  uric  acid,  a  less  oxydized  product  than  urea,  was  formed  in 
excess. 

The  causes  that  lead  to  disturbance  of  hepatic  function  are, 
in  the  great  majority  of  instances,  those  that  lead  to  gout;  but 
in  many  persons  such  functional  disorder  of  the  liver  does  not 
induce  gout,  at  least  in  any  classical  form.  It  does,  however, 
lead  to  many  symptoms  which  have  been  long  recognized 
amongst  those  of  imperfect  gout.  Such  are  certain  headaches, 
depression  of  spirits,  forms  of  migraine,  pains,  palpitation,  cramps, 
vertigo,  and  insomnia,  all  capable  of  removal  by  treatment 
addressed  to  the  liver,  which  is  commonly  somewhat  tumid  and 
painful  in  these  cases.  It  may  fairly  be  asked  why  persons  who 
thus  suffer  from  what  has  been  termed  lithaemia  yet  develop  no 
overt,  but  only  incomplete  gout  ?  The  reply  is  that  such  sym- 
toms,  though  gouty  in  character,  occur  in  persons  who  are  not 
truly  or  completely  gouty.  In  many  of  such  cases,  persistence 
in  the  habits  leading  to  the  hepatic  distemper  will,  and  indeed 


36  PATHOGENY   OF    GOUT. 

does,  ultimately  lead  up  to  overt  gout.  The  tendency  to  such 
disorder  is  probably  in  many  cases  but  a  slightly  marked  pre- 
disposition to  gout,  which  may  be  actually  inherited.  Murchison 
believed  that  this  tendency  to  hepatic  disorder  was  hereditary, 
and  I  agree  with  him.  The  urine  in  such  cases  deposits  uric 
acid  and  biurates  of  sodium,  ammonium,  potassium,  and  lime. 
The  presence  of  such  deposits  does  not  always  indicate  excess  of 
production  in  the  body.  They  may  occur  in  pyrexia,  or  after 
exercise  and  sweating,  simply  from  concentration  of  the  urine. 
Offcener  the  cause  is  an  error  in  diet,  whereby  more  nitrogenized 
matter  is  conveyed  to  the  liver  than  can  be  duly  transformed  there, 
especially  of  saccharine  and  alcoholic  matters  in  combination,  of 
fats  and  fruits,  which  interfere  with  due  chemical  transformations, 
and  induce  acid  dyspepsia.  The  same  result  follows  a  gastro- 
enteric catarrh  from  the  effects  of  cold.  Diminished  action  of 
the  skin  in  cold  weather  is  another  well-recognized  cause,  leading 
to  increased  acidity  of  the  urine.  Many  of  these  are  examples  of 
temporary  lithiasis,  which  may  occur  in  persons  having  no  claim 
whatever  to  gouty  predisposition.1 

Lithaemia,  then,  even  when  persistent,  and  not  due  to  acci- 
dental causes,  is  not  by  itself  gout.  The  muddy  and  loaded  urine 
of  the  former  state  is  commonly  of  higher  specific  gravity,  and 

i  Sir  William  Roberts  has  lately  confirmed  some  interesting  experiments  of  Dr. 
Bence  Jones,  which  indicated  that  the  amorphous  urate  deposit  is  not  wholly  or 
chiefly  composed  of  true  biurates,  but  consists  of  quadurates,  or  a  complex  com- 
pound, in  which  biurate  was  united  in  loose  combination  with  an  additional  equiva- 
lent of  uric  acid.  Amorphous  urate  treated  with  water  commonly,  but  not  always, 
throws  out  uric  acid,  and  leaves  the  associated  biurate  in  solution.  Roberts  is 
inclined  to  believe  that  uric  acid  exists  in  urine  in  the  form  of  quadurates,  and  he 
has  found  that  the  urine  prevents  the  decomposition  of  these  more  or  less  rapidly, 
according  to  its  density.  Urine  of  low  density  permits  rapid  change,  while  that  of 
medium  density  only  acts  slowly  in  throwing  out  uric  acid  from  the  deposit.  This 
fact,  which  has  been  long  known,  was  formerly  attributed  to  acid  fermentation. 
This  inhibitory  action  of  the  urine  is  believed  by  Roberts  to  be  due  to  its  crys- 
talloids— urea,  chlorides,  sulphates  and  phosphates  of  sodium,  potassium,  calcium, 
and  magnesium  ;  and  he  thus  accounts  for  the  non-precipitation  of  uric  acid  in  the 
urinary  passages  and  bladder,  decomposition  being  delayed.  The  occurrence  of  uric 
acid  in  a  free  state  in  the  urine  as  a  biurate  is  thus  attributed  to  subsequent  changes 
in  quadurates  which  take  place  in  the  urinary  passages  or  after  emission.  "  Quad- 
urate  is  very  unstable  and  susceptible  to  the  disintegrating  power  of  water.  In  the 
presence  of  alkaline  bicarbonates  it  slowly  takes  up  an  additional  atom  of  base,  and 
is  thereby  wholly  converted  into  biurate."  The  varying  state  of  the  urine  from 
time  to  time  as  to  reaction  and  concentration  will  affect  the  quadurates  dissolved  in 
it,  and  so,  Roberts  believes,  lead  to  formation  of  gravel  or  stone.  Abundance  of  salt 
in  food  or  drinking-water  has  been  shown  to  prevent  calculous  disease,  and  Roberts 
conceives  that  urinary  pigments,  for  which  urates  have  great  affinity,  also  take  part 
in  preventing  decomposition  of  these  salts.  (On  the  Amorphous  Urate  Deposit, 
Medical  Chronicle,  March,  p.  441.     Manchester,  1888.) 


AUTHORS    VIEWS.  7>7 

very  different  from  that  usually  met  with  in  the  gouty,  which  is 
clear  and  bright,  and  apt  sometimes  to  deposit  uric  acid.  The 
fact  that  lithiasis  is  frequent  in  persons  who  have  no  claim  to 
gout,  as  in  children  and  temperate  livers,  has  led  to  the  belief 
that  there  is  no  connection  between  the  tendency  to  this  state 
and  that  to  gout.  I  am  sure,  however,  that  it  is  unjustifiable  to 
insist  on  this  conclusion.  I  believe,  with  Murchison,  that  the 
tendency  to  hepatic  disorder  inducing  lithasmia  is  hereditary,  and 
it  is  certainly  met  with  in  the  children  and  descendants  of  the 
gouty.  Hence,  I  conceive  of  a  rather  close  relation  between  the 
two  states,  so  far,  at  least,  that  the  tendency  to  lithaemia  in  early 
life  may  be  an  early  expression  of  the  gouty  diathesis.  In  the 
large  cities  of  the  United  States,  lithsemiais  alleged  to  be  common, 
while  gout  is  little  known.  I  think  it  not  unlikely  that  gout 
will  become  more  common  in  that  country  in  course  of  time. 
Gout  is  a.  disease  of  old  and  long-settled  countries. 

The  lithiasis  often  seen  in  rickety  and  strumous  children  is 
probably  due  to  deficiency  of  alkaline  phosphates,  as  pointed  out 
by  Ralfe. 

The  tendency  to  persistent  or  severe  lithiasis  is  often  inherited, 
as  is  a  gouty  proclivity.  In  the  families  of  those  thus  affected, 
or  who  pass  gravel  and  develop  urinary  calculi,  it  is  very  common 
to  find  history  of  gout  and  gravel,  so  that  it  is  impossible  to 
regard  these  two  affections  as  unrelated,  and  the  one  condition 
may  most  certainly  precede,  accompany,  or  follow  the  other  in 
the  same  individual.  Temporary  cessation  of  gouty  troubles  may 
supervene  on  formation  of  calculus. 

Where  persistent  lithiasis  is  well  marked  in  early  life,  it  natu- 
rally indicates,  as  in  the  case  of  gout,  a  strongly  inherited  tendency. 

Gout  and  gravel  are,  moreover,  apt  to  alternate  in  succeeding 
generations. 

Uric  acid  is  present  in  least  quantity  in  the  body  in  the  highest 
conditions  of  health.  In  disease,  urates  commonly  increase,  and 
this  is  an  indication  of  a  lower  level  of  metabolism,  constituting, 
as  Sir  "William  Gull  has  remarked,  a  degradation  to  a  lower 
animal  type. 

The  fact  that  uric  acid  is  met  with  (in  the  form  of  salts)  in 
the  blood  both  of  healthy  persons  as  well  as  in  those  suffering  from 
morbid  states  other  than  gout,  has  made  it  difficult  to  believe 
that  blood  thus  surcharged  is  alone  to  blame  for  all  the  disturb- 
ances recognised  as  gouty.  This  fact  must  be  admitted  ;  and, 
hence,  a  purely  humoral  doctrine  is,  I  hold,  inadequate  to  explain 
the  entire  pathogeny  of  gout. 


38  PATHOGENY    OF    GOUT. 

We  have  now  to  inquire  whether,  and  if  so,  how  uric  acid 
comes  to  be  in  excess  in  the  system.  It  must  first  be  stated  that 
gout  is  not  always  evoked  by  high  living.  The  peculiar  habit  of 
body  existent  in  the  gouty  is  not  always  dependent  on  nitrogenous 
excess  for  uratic  accumulation.  Without  doubt,  other  conditions 
operate  and  lead  to  this.  Gout  will  assert  itself  in  a  gouty  indi- 
vidual under  very  varied  dietetic  habits.  To  explain  the  relation 
of  uric  acid  to  the  attacks  of  gout,  we  have  to  conceive  of  this 
peccant  matter  as  effective  only  when  in  solution  in  the  blood  or 
tissues.  Uratic  deposit  is  not,  I  believe,  always  the  cause  of 
gouty  paroxysms.  The  deposits  are  often  formed  quietly,  perhaps 
most  often  so.  They  also  occur  after  paroxysmal  attacks.  Neither 
may  we  readily  affirm  that  an  actual  excess  of  formation  of  uric 
acid  is  necessary  for  the  production  of  gout  anywhere.  It  is  now 
proved  that  uric  acid  may  be  formed  in  normal  amount  and  yet  be 
retained  in  the  body.  The  excretion  in  a  given  time  may  be  less 
than  normal,  aud  at  another  given  time  be  in  excess  of  the  due 
amount.  It  is  also  proved  that  definite  symptoms  result  from  its 
retention,  which  pass  off  with  excretion  of  that  which  has  been 
temporarily  withdrawn  from  the  circulation.  Without  actual 
excessive  formation  in  the  system,  therefore,  there  may  be,  from 
defective  excretion,  a  relative  excess  of  uratic  salts  in  the  blood 
at  a  given  time.  With  this  arises,  in  certain  individuals  only, 
tendency  to  gouty  manifestations.  The  kidneys  are  the  excretory 
organs  for  uric  acid,  and  in  very  slight  degree,  if  at  all,  sites  of 
its  formation. 

Unwonted  muscular  exercise  is  sometimes  followed  by  increased 
excretion  of  uric  acid.  It  is  also  not  an  infrequent  cause  of 
attacks  of  gout.  There  may  be  several  factors  in  the  production 
of  the  latter,  such  as  fatigue,  change  of  habit,  injury  to  or  over- 
use of  joints,  but  it  has  been  suggested  that  there  may  be  actual 
increase  in  production  of  uric  acid  in  the  system  as  the  result  of 
unusual  muscular  exertion.  Dr.  Handfield- Jones  has  related  an 
instance  apparently  illustrating  this  in  the  person  of  an  Alpine 
climber.  So  far  from  exercise  warding  off  gout,  it  induced  both 
it  and  lithiasis,  both  conditions  being  absent  during  ordinary 
home-life.1  Dr.  Handfield-Jones  argues  in  favour  of  gout  being 
produced  by  excessive  production  of  uric  acid,  as  well  as  by  reten- 
tion of  it,  due  to  renal  inadequacy.  He  also  suggests  that  the 
hypersecretion  of  uric  acid  after  great  muscular  exertion  may  be 
analogous  to  the  paralytic  secretion  which  ensues  after  section  of 
the  nerves  of  a  gland. 

i  Med.  Press,  Oct.  10,  1888,  p.  358. 


DR.    HAIGS    RESEARCHES.  39 

Dr.  Haig  1  has  contributed  valuable  facts  respecting  the  reten- 
tion of  uric  acid  in  the  body  and  its  irregular  excretion,  illustrat- 
ing clearly  in  his  own  person  that  headache  and  malaise  were 
dependent  on  retention,  definitely  and  repeatedly  induced,  and 
that  these  symptoms  were  relieved  by  means  which  set  free  the 
retained  acid.  Without  doubt,  one  relationship  of  uric  acid  to 
gouty  manifestations  appears  to  consist  in  the  remarkable  insolu- 
bility, as  before  noted,  of  this,  the  special  peccant  matter.  Another 
relationship  is  that  respecting  the  rate  of  its  elimination  from  the 
body.  Garrod  demonstrated  that  urea  is  not  excreted  in  any 
definite  relation  to  the  discharge  of  uric  acid  either  in  cases  of 
acute  or  chronic  gout.  Dr.  Haig  has  confirmed  this  observation  in 
his  researches  on  uric  acid  in  relation  to  forms  of  headache  induced 
by  uratic  retention. 

This  view  may  then  be  accepted,  that  the  excreting  functions 
of  the  kidneys  for  uric  acid  and  urea  are  separate  and  indepen- 
dent of  each  other."  Garrod  in  his  sixth  and  ninth  propositions 
maintains  the  view  that,  among  the  causes  exciting  a  gouty  fit,  is 
a  functional  failure  of  eliminating  power  for  uric  acid  on  the  part 
of  the  kidneys.  This  has  not  received,  as  yet,  any  proof.  As 
has  been  remarked  by  Dr.  Haig,  if  organic  renal  failure  existed, 
the  urea-excretion  would  probably  be  equally  affected  together 
with  that  of  uric  acid ;  but  this  is  not  the  case.  In  the  earlier 
attacks  of  gout,  at  all  events,  the  kidneys  are  presumably  healthy, 
and,  indeed,  have  been  occasionally  found  so  in  cases  where  the 
joints  have  undergone  uratic  infiltration.  In  quoting  the  views 
of  Dr.  Ralfe,  it  was  shown  that  he  doubted  Garrod's  explanation 
of  this  part  of  the  gouty  process,  maintaining,  with  many  other 
observers,  that  diminution  of  uric  acid  in  the  urine  was  chiefly  met 
with  in  cases  of  chronic  gout  with  structurally  damaged  kidneys. 

We  have  still  to  find  a  cause  for  uratic  retention  or  non- 
excretion.  Physiologists  and  chemists  have  not  yet  said  the  last 
word  either  about  the  production  or  the  destruction  of  uric  acid 
in  the  human  economy.  As  has  been  pointed  out,  a  larger  field 
for  its  production  than  the  liver,  spleen,  and  blood-glands  has 
been  hypothecated.  It  has  been  suggested  that  under  abnormal 
conditions  uric  acid  may  be  produced  in  parts  of  the  body  not 

1  Practitioner,  1884,  vol.  xxxiii.,  No.  2  ;  St.  Barth.  Hosp.  Reports,  vol.  xxiii.  p. 
201,  1887  ;  Med.  Chir.  Trans.,  vol.  lxx.,  1887.  His  researches  go  to  show  that  uric 
acid  is  not  produced  in  excess  in  the  body,  but  that  irregularities  occur  in  its  reten- 
tion and  excretion,  thus  giving  rise  to  various  symptoms. 

2  In  support  of  the  excretion  of  these  two  substances,  uric  acid  and  urea  are 
usually  found  to  be  increased  or  diminished  together.  The  relation  in  health  has 
been  found  to  be  about  1  to  33. 


40  PATHOGENY    OF    GOUT. 

usually  concerned  in  its  formation.  Thus,  Ebstein  holds  that  the 
muscles,  and  possibly  the  medulla  of  bones,  may  take  part  in  its 
production  in  the  case  of  the  gouty,  and  suggests  that  the  disease 
may  consist  in  a  diathetic  error  of  tissue-metamorphosis  present 
in  greater  or  less  degree,  perhaps  latent  in  many  predisposed  to 
gout,  and  only  capable  of  being  evoked  by  certain  determining 
causes.  "  Amongst  the  anomalies  of  tissue-change  must  be  reck- 
oned that  of  gout.  Gouty  individuals  form  uric  acid  in  perverse 
localities  in  muscles  and  bones."  If  this  view  be  accepted  in  the 
meantime,  we  may  proceed  a  step  farther,  and  conceive  that  with 
this  perverted  formation  there  may  be  also  disordered  tissue- 
metabolism,  and  the  uric  acid  be  insufficiently  reduced,  and  thus 
thrown  in  excess  into  the  blood.  If  Ebstein's  view  be  discarded, 
it  is  still  open  to  hold  the  latter  suggestion,  that,  even  with  normal 
production  of  uric  acid,  there  may  be  tissue-failure  to  dispose  of  it 
normally,  and  to  reduce  it  as  in  health. 

This  is  the  view  held  by  Dr.  Ralfe,  who  maintains  that,  in  the 
presence  of  a  free  circulation,  uric  acid  is  carried  from  its  seats  of 
production  into  the  blood  and  gradually  reduced  to  urea,  whereas, 
in  tissues  outside  the  current  of  the  circulation,  the  insoluble  acid 
is  not  so  readily  carried  off,  and,  on  slight  disturbance,  is  prone 
to  be  deposited. 

There  is  much  to  be  said  for  this  conception  of  Ebstein  as  to 
undue  formation  of  uric  acid  in  unusual  localities  in  the  case  ot 
gouty  diathesis.  In  particular,  it  affords  an  explanation  of  the 
fact  that  gout  is  something  more  than  a  functional  disorder  of  the 
liver,  which  may  lead  to  lithaemia  as  one  of  its  results,  but  goes 
no  further  in  establishing  unequivocal  gout.  Without  doubt,  there 
are  peculiarities  of  tissue  in  the  gouty,  and  with  these  may  very 
possibly  be  associated  peculiarities  of  tissue-function  and  meta- 
bolism. This  uric  acid  formative  tendency  has  been  regarded  by 
some,  notably  by  Laycock  and  Gull,  as  a  reversion  to  a  lower  type 
of  animal  tissue-metamorphosis,  wherein  this  substance  is  pro- 
duced in  place  of  more  oxydized  products  thus  rendered  soluble 
and  less  noxious  to  the  human  economy. 

Amongst  the  peculiarities  of  tissue  in  those  goutily  disposed 
has  been  observed  a  feebleness  of  capillary  circulation  at  the  peri- 
phery, a  condition  leading  to  disorders  of  chilblain-type,  the  vessels 
filling  slowly  after  being  emptied.  The  periphery  is  also  very 
sensitive  to  external  impressions. 

The  muscular  and  osseous  systems  are  often  highly  developed, 
and,  thus,  if  Ebstein's  view  be  correct,  there  are  large  fields  for 
production  of  uric  acid  in  many  cases. 


FAULTS    IN    METABOLISM.  4  I 

If  the  liver  and  blood-glands  be  not  entirely  in  fault  as  pro- 
ducing, primarily,  undue  quantity  of  uric  acid,  the  former  cer- 
tainly appears  to  suffer  from  irritation  by  noxious  products  of 
early  digestion,  which  may  cause  perverted  metabolism,  and  thus 
induce,  secondarily,  undue  formation  of  this  substance.  Evidence 
of  this  irritation  and  perversion  of  function  is  occasionally  shown 
by  the  pale  stools  which  occur  in  early  stages  of  gout,  deficient 
at  least  in  biliary  pigment,  and  sometimes  associated  with  head- 
ache or  hemicrania. 

I  think  it  may  be  fairly  conceded  that  uric  acid  is  apt  to  occur 
in  excess,  from  time  to  time,  absolutely  and  relatively,  in  the 
system  of  the  gouty.  It  is  certain  that  the  disease  occurs  under 
the  opposite  conditions  of  over-indulgence  and  strict  temperance 
both  in  meats  and  drinks.  It  is  easy  to  explain  excessive  pro- 
duction of  uric  acid  under  the  former  condition,  much  less  so 
to  account  for  the  excess  under  the  latter.  The  only  possible 
explanation  is  to  be  sought  in  the  fact  that  there  are  specific 
differences  in  the  tissue-metamorphoses  in  the  two  cases. 

Hence,  it  may  be  assumed  that  in  the  gouty  there  is  a  failure 
of  full  physiological  activity  in  the  tissues,  a  "  primordial  vice  of 
nutrition,"  as  M.  Rendu l  terms  it,  leading  to  imperfect  elaboration 
of  the  food  taken. 

Without  doubt,  the  capacity  of  individuals  to  deal  with 
certain  aliments  varies  infinitely.  These  constitute  dietetic 
idiosyncrasies,  and  they  depend  on  modes  of  intimate  tissue- 
potentiality.  These  vary  even  in  members  of  the  same  family, 
and  within  the  limits  of  health.  Mr.  Hutchinson  has  placed 
gout  amongst  the  food-diatheses,  and,  as  has  been  already  stated, 
regards  the  inheritance  of  it  as  that  of  "  a  peculiarity  of  tissue." 

We  perhaps  come  nearer  a  complete  understanding  of  this 
matter  if  we  regard  as  present  in  the  gouty  a  peculiar  incapacity 
for  normal  elaboration  within  the  whole  body,  not  merely  in 
the  liver  or  in  one  or  two  organs,  of  food,  whereby  uric  acid  is 
formed  at  times  in  excess,  or  is  incapable  of  being  duly  trans- 
formed into  more  soluble  and  less  noxious  products.  Thus,  by 
excess  of  ingesta  excess  of  uric  acid  may  be  formed,  and  by 
failure  of  tissue-transformation,  without  excess  of  uric  acid 
forming  ingesta,  excess  of  this  acid  may  be  thrown  into  the 
blood.      With  this  failure  of  normal  metabolism    for    uric    acid 

1  Nutrition  retardante  of  Beneke  and  Bouchard.  Vide  Art.  "  Goutte "  in  M. 
Dechambre's  Diet.  Encyclopedique  des  Sciences  Medicales.  This  is  a  masterly  ex- 
position of  the  whole  subject,  replete  with  learning,  and  containing  the  most  com- 
plete bibliography  relating  to  gout  ever  compiled. 


42  PATHOGENY    OF   GOUT. 

commonly  co-exists  a  like  incapacity  for  other  complete  trans- 
formations, so  that  other  imperfect  products  are  apt  to  be  thrown 
into  the  circulation  along  with  this  special  peccant  matter. 

I  am  of  opinion  that  this  incapacity  for  normal  destruction  of 
uric  acid  in  the  tissues  depends  on  disturbed  innervation.  Dr. 
Ralfe  has  expressed  himself  in  a  similar  sense. 

Having  now  ascribed  to  perverted  neuro-trophic  function  undue 
formation  of  uric  acid,  there  remains  to  be  shown  cause  for  its 
abnormal  retention  in  the  system,  which  is  allowed  on  all  hands 
to  bear  intimate  relation  to  the  manifestations  of  gout.  Dimi- 
nished alkalescence  of  the  blood  is  certainly  the  result  either  of 
undue  formation  or  of  abnormal  retention.  In  health  it  is  im- 
possible to  render  the  blood  acid.  Its  alkaline  state  is  believed 
to  be  due  to  the  excess  of  alkaline  bases  derived  from  ordinary 
aliment.  As  Sir  William  Roberts  has  suggested,  a  meal  "  is  pro 
tanto  a  dose  of  alkali,  and  must  necessarily,  for  a  time,  add  to  the 
alkalescence  of  the  blood."  Direct  experiments  have  proved  the 
truth  of  this,1  and  of  the  effects  of  meals  in  inducing,  as  a  con- 
sequence, an  alkaline  condition  of  the  urine  for  a  subsequent 
period.  This  "  alkaline  tide,"  as  it  has  been  termed,  ebbs  after  a 
time,  and  with  fasting  the  urine  steadily  resumes  an  acid  reac- 
tion. As  pointed  out  by  Roberts,  the  reaction  of  the  urine 
plainly  reflects  the  condition,  for  the  time  being,  of  the  blood, 
one  function  of  the  kidneys  being  to  regulate  the  reaction  of  the 
blood.  It  is,  therefore,  possible  to  influence  this  condition  of  the 
blood  by  giving  food,  or,  in  another  way,  by  directly  administer- 
ing alkalies,  to  produce  alkalinity.  With  respect  to  acids,  it  is 
found  impossible  to  acidulate  urine  except  in  the  very  peculiar 
way  that  this  may  be  achieved  by  means  of  benzoic  acid.  All 
this  is  true  of  a  healthy  individual.  In  discussing  this  question 
in  relation  to  headaches  produced  by  retention  of  uric  acid,  Dr. 
Haig,  in  his  able  and  suggestive  research,  inquires  pertinently 
whether  in  abnormal  conditions  we  may  not  meet  with  variations 
in  the  alkalescence  of  the  blood  and  tissue-fluids,  and  of  the  liver 
and  spleen,  sufficient  to  produce  fluctuations  in  the  excretion  of 
uric  acid.  He  proved  in  his  own  case  that  animal  food  led  to 
retention  of  uric  acid,  and  that  vegetable  food  promoted  excretion 
of  it,  and  he  argues :  "  If  an  ordinary  meal  is  a  dose  of  alkali,  a 
somewhat  vegetarian  meal,  from  which  butcher's  meat  and  beer 
are  absent,  must  surely  be  a  large  dose  of  alkali,"  and,  thus,  both 
promote  greater  alkalescence  of  the  blood  and  prevent  uric  acid 
retention. 

1  Op.  cit.,  p.  56. 


URIC    ACID    RETENTION.  43 

Dr.  Haig  suggests,  further,  that  the  gouty  somewhat  resemble 
vegetable  feeders  in  having  less  than  the  normal  power  of  form- 
ing ammonia  to  resist  acids,  and  prevent  their  taking  alkali  from 
the  blood.  By  persistence  in  animal  food  and  strong  liquors,  he 
thinks  the  alkalinity  of  their  blood  and  fluids  is  so  far  overcome 
that  urates  will  be  less  soluble  in  them  than  in  the  normal  con- 
dition. This  theory,  I  think,  affords  a  valuable  illustration  of 
the  tissue-incapacity  already  alluded  to.  Guided  by  this  concep- 
tion, which  is  founded  on  definite  observations  in  several  instances, 
we  may  fairly  believe  that  in  persons  of  gouty  habit  excess  of 
nitrogenous  diet,  or  definite  additions  of  acids  or  acid  liquors, 
such  as  beer  and  wines,  or  fruits,  lead  to  retention  of  uric  acid  in 
the  blood,  and  especially  in  the  liver  and  spleen,  because  their 
tissues  are  less  alkaline  than  those  of  many  other  organs.  Dr. 
Haig  suggests  "  that  a  dose  of  acid  in  these  persons  increases  the 
acidity  of  the  liver  and  spleen,  and  causes  increased  retention  of 
uric  acid  in  them,  while  a  dose  of  alkali  will  diminish  their 
acidity,  and  sweep  out  the  uric  acid  accumulated  there,"  thus 
giving  rise  to  various  symptoms. 

Garrod's  view  as  to  retention  was  based  on  an  assumed  renal 
incapacity ;  but  it  is  certainly  not  proved  that  such  incapacity 
exists  in  the  earlier  stages  of  gout.  It  might,  perhaps,  be 
assumed  as  part  of  the  tissue-peculiarity  of  the  gouty.  In  con- 
sidering the  phenomena  of  a  paroxysmal  attack,  the  influence  of 
the  nervous  system  following  shock,  depression,  or  any  violent 
interference,  must  not  be  left  out  of  account  as  a  possible  deter- 
mining factor  for  renal  inadequacy.  This  is  well  ascertained  in 
hysteria.  Anuria,  from  suppression  in  such  cases,  has  been 
described  by  Laycock  and  by  Charcot.  Laycock  believed  that 
a  measure  of  renal  inadequacy  occurred  in  such  cases  of  gout  as 
were  induced  in  early  life  by  excessive  venery  and  alcoholic 
stimulation,  owing  to  reflected  exhaustion  of  the  nervous  system 
of  the  genitalia,  these  organs  being  closely  related  embryologi- 
cally.  By  the  light  of  Dr.  Haig's  researches,  we  are  justified  in 
believing  that  temporary  retention  in  the  system,  probably  in  the 
liver,  spleen,  and  other  glands,  leads  to  such  fluctuations  in  the 
alkalinity  of  the  blood,  and,  coincidently,  in  the  excretion  of  uric 
acid  by  the  kidneys,  as  may  fairly  explain  some  of  the  humoro- 
pathogenetic  relations  of  gout,  and  apparent  arrest  of  renal 
function. 

His  facts  are,  that  there  is  diminished  excretion  of  uric  acid 
before,  and  increased  excretion  of  it  after,  the  nervous  disturbances 
induced  by  it. 


44  PATHOGENY    OF    GOUT. 

With  the  induction  of  a  well-established  gouty  habit,  we  must 
suppose  a  more  permanent  change  in  the  natural  alkalescence  of 
the  blood  due  to  retained  uric  acid,  and  with  this  a  tendency, 
under  certain  provocations,  to  deposition  in  different  parts  of 
the  body. 

The  conditions  leading  to  excretion  are  related  to  the  alkaline 
tide  of  early  digestion,  and  those  concerned  in  retention  are  associ- 
ated with  later  digestion,  and  the  acid  tide  of  this  period  and  of 
sleep,  as  indicated  by  Dr.  Haig. 

According  to  Lecorche,  the  gouty  state  is  due  to  the  transfor- 
mation of  uric  acid  into  acid  biurate.  This  is  brought  about  by 
such  causes  as  generally  lessen  the  alkalinity  of  the  blood.  He 
denies  that  gout  is  a  malady  induced  by  retarded  nutrition,  but 
is  characterized  rather  by  hypernutrition  with  exaggeration  of 
molecular  work. 

The  essential  humoral  feature  of  the  gouty  state  is  the  presence 
in  abnormal  amount  of  uric  acid  salt  in  the  blood  and  tissues.  So 
long  as  this  condition  prevails,  the  patient  is  gouty,  and  unless  the 
excessive  amount  be  reduced  by  preventive  and  medicinal  measures, 
this  state  is  apt  to  be  maintained  or  to  recur. 

It  now  remains  to  correlate  the  two  pathogenetic  factors  con- 
cerned in  the  production  of  a  paroxysm  or  overt  attack  of  gout, 
namely,  the  nervous  and  humoral  parts  of  this  process. 

It  has  already  been  shown  that  the  nervous  system  of  the 
gouty  is  peculiarly  sensitive,  and  predisposed  to  instability  in 
certain  directions.  This  condition,  together  with  the  peculiar 
tissue-state  of  the  gouty,  itself,  as  I  believe,  dominated  by  trophic 
nerve-influences,  affords,  probably,  a  fairly  complete  conception  of 
the  malady  in  question.  As  already  affirmed,  neither  condition 
by  itself  suffices  to  explain  the  recognized  characters  of  gouty 
disease.  Thus,  the  peculiar  state  of  the  blood  has  been  shown  to 
be  insufficient  by  itself  to  set  up  the  phenomena  of  gout,  and  the 
condition  of  the  nervous  system  may  be  latent  in  respect  of 
revealing  (painful)  symptoms  of  overt  gout.  We  must  then 
regard  the  nervous  factor  or  element  as  dominating  specifically 
the  several  definite  features  of  gouty  manifestations.  We  may- 
assume  that  the  chain  of  morbid  events  has  its  origin  in  irritation 
of  the  nervous  system,  or  of  some  part  or  parts  of  it,  by  the 
peccant  matter  thrown  into  the  circulating  fluids  of  the  body, 
and  that,  thus,  misemployment  of  nerve-force  occurs,  determining 
definite  paroxysms  or  local  manifestations  in  one  or  more  parts 
of  the  frame.      At  this  point  I  must  refer  to  the  view  expressed 


INFLUENCE  OF  THE  NERVOUS  SYSTEM.        45 

in  an  earlier  portion  of  this  chapter  respecting  gout  regarded 
as  a  diathetic  neurosis,  due  to  a  centi-al  neurotic  taint,  and 
originating  from  prolonged  toxaemia.  This  I  termed  primary  or 
central  gout.  This  view  is  conceivable  as  the  result  of  inherited 
gouty  propensity,  but  can  perhaps  hardly  be  admitted  as  all- 
explaining  without  acceptance  of  the  further  view  as  to  a  more 
widely  spread  complicity  of  other  tissues  in  the  manner  already  set 
forth.  The  morbid  disposition  may  well  exist  in  more  marked 
degree  in  some  instances  in  one  than  in  the  other  direction,  and 
in  the  most  pronounced  conditions  we  may  regard  both  the 
nervous  system  and  the  tissues  generally  as  involved  for  the 
production  of  gout. 

In  another  class  of  cases,  where  the  disease  is,  as  it  were,  quiet, 
latent,  or  not  paroxysmal,  we  may  fairly  suppose  that  some 
nervous  manifestations  usually  present  are  from  some  cause  in 
abeyance.  For  example,  the  most  exquisite  gout  in  respect  of 
tophaceous  deformity  may  grow  up  in  various  parts,  constituting, 
as  Todd  believed,1  a  special  clinical  variety,  without  a  single 
twinge  of  pain  or  symptoms  of  nervous  disturbance.  The  nervous 
element  in  such  a  case  may  have  been  only  so  far  abnormally 
evoked  as  to  determine  the  special  locality  affected  in  this  manner. 
We  cannot  doubt  the  influence  of  nervous  force  in  any  form  of 
nutrition,  whether  normal  or  morbid,  and  we  can  conceive  per- 
turbations of  it  as  exciting,  if  not  determining,  perverse  trophic 
changes. 

A  complete  conception  of  gout  necessarily  entails  a  considera- 
tion of  the  inflammatory  processes  associated  with  certain  of  its 
manifestations.  We  need  not  invoke  any  special  factors  in  this 
connection.  Gouty  inflammation  resembles  most  other  forms  of 
this  disturbance,  with  perhaps  one  exception,  viz.,  the  well-known 
absence  of  tendency  to  suppuration.  There  are  specific  pecu- 
liarities, moreover,  relating  to  suddenness  of  onset,  intensity  and 
fugacity  of  pain,  and  conditions  attending  such  a  process  in  parts 
which  are  non-yielding  and  non-vascular. 

In  respect  of  gouty  as  of  other  inflammations,  we  must  admit 
the  influence  of  perverted  nerve-force  in  inducing  alteration  both 
of  quality  and  quantity  in  nutritive  fluids.  Herein  lies  part  of 
the  specificity  of  the  gouty  process.  There  is,  as  I  have  already 
■maintained,  a  special  mode  of  nervous  evolution  dominating  many 
of  the  phenomena  of  gout,  and  this  marks  off  the  peculiar  diathesis 
as  certainly  and  significantly  as  does  the  altered  blood-state.  We 
find,  therefore,  a  twofold  inheritance  in  respect  of  nerve-evolution 

1  Clin.  Lectures,  Urinary  Diseases,  p.  425,  i860. 


46  PATHOGENY   OF   GOUT. 

and  toxsemia,  or  tendency  thereto,  not  always  inherited  in  the 
same  degree,  or  even  equally  in  respect  of  the  two  states. 

Where  no  inheritance  is  traceable,  we  may  conceive  that,  as  a 
result  of  the  primary  induction  of  toxsemia  by  over-indulgence, 
changes  are  set  up  in  the  nervous  system  leading  to  the  specially 
perverted  manifestations  of  nerve-force  which  constitute  that  part 
of  the  gouty  pathogeny.  And  in  our  conception  of  the  part 
played  by  the  latter,  we  must  not  lose  sight  of  the  larger  and 
more  wide-spread  influence  of  nerve-force  upon  intimate  tissue- 
metabolism,  which  may  be  highly  effective,  though  at  present 
undemonstrable  and  almost  inscrutable. 

We  must  next  seek  to  discover  some  of  the  special  perverted 
modes  of  action  determining  overt  gout. 

It  is  an  axiom  in  pathology  that  a  change  in  any  part  may,  by 
altering  its  relation  to  the  blood,  alter  its  mode  of  nutrition.  In 
this  manner  injuries  to  parts  lead  to  altered  nutrition,  and  render 
them  more  vulnerable  and  open  to  inflammatory  or  other  changes. 
In  healthy  persons  such  changes  possess  no  specific  characters,  but 
in  persons  the  subject  of  any  diathesis,  these  changes  will  cer- 
tainly be  modified  in  some  definite  manner  according  to  the  spe- 
cificity of  the  habit  of  body.1  Thus  come  out  the  characters  of 
specific  disease,  and  to  induce  these  there  must  be,  as  has  been 
pointed  out  by  Paget,  at  least  two  factors — the  morbid  matter  in 
the  blood,  and  the  presence  of  a  part  of  the  organism  specially 
adapted  for  this  matter  to  effect  its  malign  purpose. 

To  apply  these  views  to  the  case  of  localized  gouty  manifesta- 
tions is  not  a  hard  task.  It  is  well  known  that  parts  which  have 
been  injured,  strained,  or  overworked  are  just  the  sites  in  which 
gout  is  apt  to  appear.  All  such  influences  are  calculated  to 
impair  and  depress  the  nutrition  of  the  textures  involved.  They 
are,  therefore,  more  than  other  parts  vulnerable,  sensitive,  and 
laid  open  to  attack.  The  blood  is  the  medium  wherein  the 
peccant  matter  of  the  disease  lies,  and  a  special  elective  affinity 
is,  as  it  were,  established  between  the  weak  part  and  the  dis- 
tempered blood. 

We,  thus,  understand  how  uratic  deposit  is  determined  at  cer- 
tain points  whose  nutritional  standard  is  lowered  or  altered  for 
the  worse.      Amongst  parts  specially  exposed  to  strain  and  hurts, 

1  "  Le  traumatisme  eveille  souvent  la  predisposition  diathesique." — M.  Rendu. 

"  An  injured  part  may  become  the  seat  of  gouty  disease  in  one  gouty.  .  .  .  Thus, 
in  diseases  recognized  as  specific,  in  those  that  certainly  have  a  specific  morbid  mate- 
rial in  the  blood,  we  recognize  a  local  injury  or  irritation  as  making  a  part  susceptible 
or  apt  for  the  manifestation  of  the  specific  morbid  changes." — Paget,  Morton  Lecture, 
1887. 


URIC   ACID    STASIS.  47 

none  suffer  more  than  joints,  and,  hence,  probably  the  explanation 
of  the  inordinate  incidence  of  gout  upon  these  structures,  espe- 
cially witnessed  in  the  joints  of  the  great-toe,  the  knee,  and  the 
hands.  I  believe  that  this  view  holds  good  both  for  imperfectly 
developed  and  for  paroxysmal  forms  of  gout.  Other  textures  than 
joints  are  sites  of  gouty  election  ;  thus,  we  meet  with  uratic  depo- 
sits in  other  tissues,  but  with  especial  frequence  in  such  as  have 
inactive  circulation,  such  as  sheaths  of  tendons,  and  the  skin  over 
various  regions. 

Many  of  the  lesser,  though  painful,  manifestations  of  gout  are 
due,  I  believe,  to  temporary  stasis,  if  not  to  deposition  of  uratic 
salts,  even  in  viscera  with  active  circulation,  such  as  the  liver,  or 
in  synovial  sacs,  nerve-sheaths,  and  lymph-spaces.  No  unequi- 
vocal proof  of  this  is  forthcoming,  but  its  likelihood  is  established 
by  the  fact  of  their  occurrence  in  gouty  persons,  and  by  the  happy 
results  of  anti-gouty  treatment  which  removes  them.  In  the  kidney 
the  presence  of  urates  in  the  adult  may  safely  be  taken  as  an 
indication  of  gout,  and  when  found  here,  they  will  seldom  be 
found  absent  from  the  smaller  joints.  Even  in  cases  of  this  kind 
there  may  be  no  history  of  paroxysmal  gout.  The  phenomena  of 
an  acute  attack  bear  some  resemblance  to  those  seen  in  a  specific 
fever.  Indeed,  the  older  physicians  placed  gout,  nosologically, 
amongst  the  fevers.1  The  sudden  paroxysm,  the  local  signs,  the 
crisis,  and  the  subsequently  amended  health,  are  all  comparable 
with  the  series  of  events  witnessed  in  an  exanthematous  fever, 
and  are  fairly  analogous  as  indicating  the  certain  effects  of  dis- 
tempered blood-state.  The  characters  of  gouty  pyrexia  will  be 
given  subsequently.  Those  relating  to  the  paroxysm  and  its  fre- 
quent suddenness  now  demand  attention  while  discussing  the 
pathogenic  relations  of  the  disorder.  It  has  always  been  difficult 
to  account  for  the  explosive  features  of  gout.  These  vary  much 
in  different  individuals,  and  even  in  the  same  patient.  A  bad 
attack  will  establish  itself  within  a  few  minutes,  and  an  equally 
bad  one  will  sometimes  take  many  hours  to  reach  the  same  degree 
of  severity.  Fagge  regarded  a  paroxysmal  attack  in  the  light  of  an 
accident  occurring  in  the  course  of  an  essentially  chronic  change 
in  the  joint  affected.  It  may  be  believed  that  the  conditions  lead- 
ing up  to  the  attack  have  been  some  time  previously  in  operation, 
the  blood  becoming  more  impregnated  with  urates.  Some  deter- 
mining factor  must  now  be  invoked  to  explain  how,  as  it  were, 

1  The  great  Boerhaave  believed  that  gout  was  contagious  (Aph.  1255).  Vide 
Translation  of  van  Swieten's  Commentaries  upon  Boerhaave's  Aphorisms,  vol.  xiii. 
P-  27,  1775- 


48  PATHOGENY    OF    GOTJT. 

the  train  is  fixed.  The  fact  that  paroxysms  have  been  induced 
by  a  heavy  meal,  or  by  a  single  indulgence  in  certain  liquors,  is 
probably  in  part  explained  by  the  sudden  addition  to  the  system 
of  more  materials  than  can  be  dealt  with  by  the  organs  and  tissues 
engaged  in  metabolic  functions,  and  these  are  probably,  as  has 
been  shown  in  many  cases,  at  the  best,  specifically  impaired  or 
inadequate  in  the  gouty.  The  same  result  may  also  be  caused  by 
the  effect  of  cold,  throwing  increased  work  on  internal  organs, 
which  by  checking  perspiration  diminishes  the  alkalescence  of  the 
blood,  and  so  leads  to  precipitation  of  urates. 

If  the  kidneys  are  healthy,  it  is  not  easy  to  suppose  that,  as 
has  already  been  stated,  any  special  functional  inactivity  exists 
leading  to  defective  excretion.  These  organs  may,  however,  be 
specially  prone  in  the  gouty  to  be  nervously  impressed.  It  may, 
however,  be  here  noted  that  some  liquors,  especially  wines,  vary 
much  in  their  effects  on  the  kidneys.  Those  which  promote 
diuresis  are  usually  the  least  gout-provoking,  and  vice  vcrsd — a  point 
to  be  discussed  in  future  under  the  head  of  dietetics. 

I  believe  that,  in  order  to  explain  the  explosive  characters  of  a 
gouty  paroxysm,  we  must  look  to  the  nervous  elements  of  the  case. 
Not  only  are  excessive  diet  and  over-indulgence  in  liquors  to 
blame  as  exciting  causes.  Were  these  factors  alone  potent,  how 
then  shall  we  explain  the  well-ascertained  fact  that  the  same 
phenomena  supervene  on  mental  causes,  such  as  shock,  or  after 
fatigue  and  exhaustion,  which  can,  and  must,  act  alone  through 
the  agency  of  the  nervous  system  ?  I  have  already  endeavoured 
to  show  that  this  system  is  peculiarly  disposed  and  impressible  in 
the  gouty,  evincing  instability  and  undue  sensitiveness,  and,  hence, 
I  am  led  to  believe  that  to  its  influence  is  to  be  ascribed  much 
that  dominates  the  manifestations  of  the  paroxysm.  Hence,  we 
may  conceive  the  paroxysm  as  resulting  from  an  interruption  of 
what  I  would  term  the  trophic  equilibrium  of  the  body.  Thus, 
the  tendency  to  nocturnal  seizure,  the  extraordinary  pain,  and  the 
other  features  already  alluded  to  in  the  section  on  neuro-patho- 
geny.  Hence,  it  is  not  the  quiet  deposition  which  determines  a 
paroxysm  in  a  part,  but  the  presence  of  excess  of  uric  acid  in 
solution  in  the  tissues  which  is  thus,  together  with  specially  deter- 
mined nervous  influence,  potent. 

I  have  already  discussed  the  line  of  action  which  is  assumed  as 
that  of  nervous  influence  upon  joints,  viz.,  the  proposition  which 
regards  articular  affections  as  due  to  irritative  states  of  the  spinal 
axis  and  sympathetic  system,  and  have  ventured  to  express  my 
belief  that  this  is  essentially  necessary  for  a  complete  conception 


THE  PHYSICAL  THEORY  OF  GOUT.  49 

of  the  arthritic  habit  of  body  as  evinced  in  both  gouty  and 
rheumatic  diseases.  The  occurrence  of  one-sided  manifestations 
of  arthritism,  e.g.,  joint-affections,  hemicrania,  and  neuralgia, 
which  have  been  well-established  in  certain  cases,  indicate  still 
further  a  dominating  nervous  influence.  M.  Henry  Cazalis,  of 
Aix-les-Bains,  has  directed  attention  to  these  cases,  and  he  notes 
that  these  unilateral  manifestations  are  most  frequently  right-sided.1 

I  have  notes  of  several  cases  in  which  articular  paroxysms 
occurred  with  greater  frequency  and  intensity  on  one  or  other 
side  of  the  body,  no  determining  cause  being  made  out  in  any 
case.  I  lay  no  stress  on  the  facts.  Acute  attacks  had  occurred 
on  both  sides  in  many  of  the  cases.  There  is,  doubtless,  some 
cause  for  the  limbs  on  one  side  suffering  more  than  those  on  the 
other,  but  there  is  at  present  no  known  explanation  of  the 
fact. 

A  mere  physical  theory  of  gout,  such  as  is  now  much  held  in 
Germany,  hypothecates  local  stasis  of  uric  acid  in  certain  textures 
and  situations,  and  allows  that  in  the  more  vascular  parts  this 
excess  can  be  carried  away  by  the  vigour  of  the  circulation,  and 
taken  into  the  blood  in  solution.  In  less  vascular  areas  or  non- 
vascular tissues,  such  as  cartilages,  and  those  of  the  latter,  in  par- 
ticular, most  peripherally  situated,  the  force  of  the  blood-current 
is  too  feeble  to  carry  off  such  deposits,  and,  hence,  persistent  stasis 
with  a  gouty  paroxysm. 

On  this  theory,  local  influences  have  much  to  do  with  the 
determination  of  attacks,  and  it  is  not  even  necessary  to  believe 
that  there  is  any  absolute  excess  of  uric  acid  in  the  system  on  the 
occurrence  of  a  paroxysm. 

Although  very  ingenious,  I  am  not  prepared  to  accept  this 
purely  physical  view  of  the  pathogeny  of  gout  as  sufficiently 
explanatory  of  all  the  phenomena.  Neither  is  a  purely  chemical 
theory  adequate  for  this  purpose.  It  is  incumbent,  I  believe,  to 
invoke  not  only  a  chemical  and  a  physical  basis  for  gouty  disease, 
but  to  include  also,  in  a  comprehensive  view,  the  marked  deter- 
mining influence  of  the  nervous  factor  in  the  problem. 

It  appears  to  be  proved  by  Garrod  that  the  inflammation  in  a 
gouty  attack  tends  to  the  destruction  of  the  urates  in  the  blood- 
inflamed  part.  It  is,  however,  difficult  to  believe  that,  as  Garrod 
further  maintains,  this  local  change  is  sufficient  to  clear  the  system 
from  the  uratic  excess  present  at  such  a  time.      The  quantity 

1  Note  nouvelle  sur  V ' Hemi-Rlmmatisme,  Jour,  de  Med.,  Paris,  1  Mai  1887.  La 
Predominance  Hemi-laterale  des  Manifestations  du  Ehumatisme  Chronique,  Communi- 
cation a  V Acad,  de  M&lecine. 

D 


50  PATHOGENY    OF    GOUT. 

deposited  locally  with  each  attack  is  probably  insufficient  to  explain 
so  much  elimination  as  may  be  presumed  to  occur,  for,  along  with 
destruction  in  the  tissues  due  to  inflammation,  fresh  deposit  is 
laid  down.  After  each  attack  the  system  is  certainly  relieved, 
and  better  health  is  established.  Hence,  it  may  fairly  be  assumed 
that  the  uratic  excess  in  the  blood  is  dissipated  and  disposed  of. 
An  argument  in  favour  of  such  eliminant  or  destructive  action 
being  due  to  the  inflammatory  attack,  or  conditions  attendant 
on  this,  may,  however,  be  adduced  from  the  fact  that  some  of 
the  most  bulky  deposits  occur  in  parts  which  have  never  been 
the  seat  of  acute  paroxysms,  or  only  of  slight  inflammatory 
attacks. 

This  point  did  not  escape  the  acumen  of  Sydenham.  He 
remarked,  "  In  gout,  however,  it  seems  as  if  it  were  the  pre- 
rogative of  Nature  to  exterminate  the  peccant  matter  after  her 
own  fashion,  to  deposit  it  in  the  joints,  and  afterwards  to  void  it 
by  insensible  perspiration."  He  alludes  to  the  relief  afforded  by 
morning-sweats  after  the  pain  and  restlessness  of  a  night  of  gouty 
suffering.  Todd  observed  that  sweating  relieved  the  pain  of 
gout.1  Doubt  has  been  cast  on  the  eliminant  power  of  the 
sweat-glands  for  the  removal  of  uratic  salts  from  the  body. 
Garrod,  in  particular,  denies  this,  having  failed  to  find  any  uric 
acid  in  sweat  procured  from  gouty  patients  after  a  Turkish  bath. 
Dr.  Tichborne,  of  Dublin,  however,  has  succeeded  in  detecting  it 
under  similar  circumstances,  and  maintains  that  the  colloidal 
character  of  uric  acid  permits  it  to  dialyse  through  animal  mem- 
branes, this  property  being  augmented  by  a  temperature  such  as 
that  of  the  body.  I  have,  however,  failed  to  find  it  in  two  cases 
examined  by  Tichborne's  method. 

I  have,  nevertheless,  little  doubt  that  the  skin  is  a  channel  for 
removal  of  some  of  the  excess  of  uratic  acidity  met  with  in 
gout. 

It  may  be  that  the  articular  sites  of  predilection  are  determined 
by  nervous  (neuro-trophic)  influences.  Of  this  we  are  not  yet 
sure.  I  think  it  certain  that  deposits  may  occur  in  joints  long 
before  any  classical  attack  of  gout  supervenes  in  them,  and  such 
may,  indeed,  never  be  developed.2  It  is  also  certain  that,  in  most 
instances,  an  attack  of  gouty  inflammation  leaves  behind  it  uratic 
deposit.     But  gout  can  induce  many  other  and  grosser  changes  in 

1  Clin.  Lectures  on  Urinary  Diseases,  p.  413.  Lond.,  1857.  The  proportion  of 
uric  acid  in  the  urine  has  been  shown  to  be  diminished  by  diaphoresis.  Wilson 
Philip. 

2  This  was  noted  by  Scudamore,  op.  eit.,  p.  145. 


RELATION  BETWEEN  GOUTY   DEPOSITS  AND  SYMPTOMS.       5  I 

parts  beyond  mere  uratic  deposition.  These  will  be  referred  to 
under  the  head  of  morbid  anatomy. 

Uratic  deposit  is  certainly  found  most  abundantly  in  parts  that 
are  least  vascular  and  peripherally  placed  in  respect  of  the  circu- 
lation. We  must  now  discuss  the  relations  of  this  deposition  to 
the  whole  disease,  whether  in  the  latent  or  the  paroxysmal  form. 
It  has  been  supposed  that  by  this  means  the  excess  of  uratic  salt 
in  the  blood — a  recognized  factor  in  the  case — is  so  far  eliminated, 
or  shut  off,  from  the  system.  Garrod  has  demonstrated  that  gouty 
inflammation  is  always  accompanied  by  deposit  of  urates  in  the 
affected  part,  and  that  this  deposit  is  permanent.1  It  is  also 
proved  that  this  deposition  may  proceed  without  any  inflam- 
matory symptoms,  as  commonly  recognized.  Garrod  believes  that 
the  deposition  is  the  cause  of  the  inflammation. 

If  this  proposition  be  put  forward  without  further  qualifica- 
tion, it  cannot  be  sustained,  for  the  reason  just  mentioned.  I 
believe  that  it  holds  good  in  many  cases,  and  is,  indeed,  the  only 
explanation  forthcoming,  at  present,  for  explosive  attacks.  Even 
in  cases  where  latent  deposit  has  already  taken  place,  I  believe 
the  supervention  of  a  more  pronounced  gouty  state  will  lead 
up  to  paroxysmal  attacks  in  a  part  already  the  seat  of  quiet 
gouty  change.  The  condition  may  therefore  be  very  largely  but 
a  quantitative  one.  Hence,  I  cannot  quite  accept  Dr.  Ord's  view 
that  "  the  local  processes  are  not  dependent  on  these  deposits." 
I  would  say,  "  are  not  always  dependent,"  for  I  conceive  that, 
with  a  large  excess  of  urates  in  the  blood,  local  inflammatory 
changes  may  be  set  up.  A  certain  amount  of  deposition  is 
tolerated,  a  larger  amount  is  resented,  and  excites  violent  reac- 
tion. The  conditions  determining  these  phenomena  probably 
relate  to  personal  peculiarities,  the  degree  of  inheritance  and 
range  of  the  disorder,  and  they  have  to  do  with  the  age,  tissue- 
state,  and  general  vigour,  or  the  reverse,  of  the  individual.  These 
personal  factors,  indeed,  can  never  be  lost  sight  of  in  any  case. 

When  a  gouty  habit  of  body  is  established,  the  causes  already 
enumerated  tend  to  operate  more  readily  and  with  less  provo- 
cation. With  failure  of  nervous  power  comes  less  reaction,  and  a 
more  tedious  and  atonic  process  both  of  development  and  dura- 
tion. Tissue-degenerations  make  progress,  set  up  both  by  fail- 
ing neuro-trophic  influence,  and  by  direct  action  of  retained 
peccant  matters.     The  kidneys,  in  particular,  now  become  struc- 

1  From  some  examinations  made  after  death,  in  cases  where  the  history  clearly 
pointed  to  gout  in  certain  joints,  I  am  disposed  to  question  the  unvarying  certainty 
of  permanent  deposit. 


52  PATHOGENY    OP    GOUT. 

turally  involved,  and  a  permanent  inadequacy  of  their  functions 
supervenes.  This  condition  constitutes  what  is  termed  the  gouty 
cachexia.  But  not  in  all  cases  does  the  gouty  diathesis  progress 
towards  its  corresponding  cachexia.  The  disposition  exists  in 
very  varying  degrees  of  intensity.  There  may  be  only  slight 
indications  of  its  presence,  or  but  a  few  overt  paroxysmal  attacks 
in  a  lifetime,  and  the  habit  of  body  may  but  modify  any  super- 
added morbid  conditions,  and  not  itself  lead  directly  to  death. 
Inherited  gout  is  the  most  obstinate,  because  most  fully  deve- 
loped. The  two  essential  factors  concerned  in  the  production 
of  the  disorder  may  be  inherited,  probably,  in  varying  pro- 
portion. 

The  tissue-defect,  or  uric  acid-forming  tendency,  may  be 
more  pronounced  than  the  neurotic  element,  and  vice  versa. 
Circumstances  of  life,  propensities,  and  habits  may  readily  evoke, 
repress,  or  accentuate  each  of  these,  and,  thus,  determine  the 
range  of  action  of  each  in  any  given  case. 

In  this  manner  we  are  enabled  to  explain  many  of  the  varied 
features  of  the  disease  which  present  themselves.  Thus,  a  man 
may  be  gouty  without  having  what  is  commonly  called  gout. 
There  may  be  gouty  disease  of  the  kidneys  without  uratic 
arthritis,  although  in  many,  but  not  in  all,  of  such  cases,  quiet 
deposits  of  urates  may  be  found  in  certain  joints.  The  par- 
oxysmal (neurotic)  element  is  in  abeyance  in  such  cases.  Clini- 
cally, such  cases  are  recognized  as  gouty  by  various  features  in 
their  history  and  progress.  The  diagnosis  is  not  rendered  abso- 
lutely certain  till  the  particular  form  of  kidney-change  and  the 
deposits  are  manifested  at  the  necropsy. 

In  persons  under  forty  years  of  age,  we  are  often  justified  in 
prognosticating  at  some  future  time  the  onset  of  regular  gout  by 
the  special  morbid  tendencies  exhibited,  the  irregular  or  incom- 
plete gouty  nature  of  the  symptoms  indicating  what  is  in  course 
of  fuller  development,  unless  effectually  checked  by  a  change  of 
habits  and  by  direct  treatment.  This  is,  happily,  not  an  im- 
possible achievement  in  preventive  medicine,  and,  hence,  the  value 
of  a  due  recognition  of  these  manifestations  and  untoward  ten- 
dencies in  early  life,  an  accurate  knowledge  of  family  history 
being  amongst  the  most  important  facts  to  be  sought. 

I  come,  lastly,  to  consider  the  question  as  to  the  specific  im- 
portance of  uratic  deposits  as  alone  significant  in  any  case  of 
gout  or  goutiness.  It  may  appear  to  savour  of  heterodoxy  to 
entertain  any  doubt  on  this  point. 


SIGNIFICANCE    OF    GOUTY    DEPOSITS.  53 

The  real  issue  is  not  as  to  the  existence  of  urichaemia,  which 
must  be  absolutely  accepted  in  any  given  case,  but  as  to  the 
presence  of  deposited  urates  in  some  locality.  It  can  hardly,  I 
think,  be  doubted  that  lesions  result  from  the  action  of  uric  acid 
in  solution  in  the  tissues,  and  that  thus  both  acute  and  chronic 
inflammatory  changes  may  be  set  up  without  the  direct  influ- 
ence of  uratic  deposit  as  an  alleged  irritant  in  joints  and  in  cer- 
tain viscera,  notably  in  the  kidneys.  Degenerative  changes  and 
necrosis  also  appear  to  be  thus  induced. 

I  think  we  here  witness,  as  Ebstein  puts  it,  the  results  of 
local  uric  acid  stasis  in  the  one  case,  and  of  general  stasis  in  the 
other. 

A  study  of  the  morbid  anatomy  of  gout  appears  to  justify 
the  views  held  by  Drs.  Ord,  Norman  Moore,  and  others,  that 
deposits  never  occur  but  in  tissues  which  have  already  begun  to 
degenerate. 

I  must  express  my  belief,  after  much  observation  and  long  re- 
flection on  the  whole  matter,  that  the  presence  of  uratic  deposit  is 
not  absolutely  indispensable  for  the  determination  of  gouty  disease 
or  manifestation.  I  believe  that  all  the  essential  elements  of  the 
morbid  process  may  be  present  in  cases  without  this  particular 
expression  of  it  in  the  form  of  what  is  termed  "  frank  "  gout.  The 
facts  on  which  I  base  my  conviction  may  possibly  not  avail  to 
carry  proof  to  many.  First,  I  would  affirm  that  within  the 
domain  of  pathology  we  meet  with  morbid  states  in  very  varying 
degrees  of  intensity.  We  have  more  or  less,  and  we  have  always, 
the  personal  factor  in  each  case,  including  the  degree  of  inherit- 
ance, its  modification,  and  the  measure  of  vulnerable  reaction  in 
the  textures  specifically  invaded  or  impressed.  Secondly,  I  note 
that  with  very  trifling  degree  of  uratic  deposit,  a  great  deal  of 
other  recognizable  gouty  disease  may  be  present  in  a  given 
subject,  as,  for  example,  granular  kidney  (nephritis  arthritica 
so-called),  cardio-vascular  change,  and  the  like,  leading  to  fatal 
result.  Thirdly,  I  think  it  permissible  to  claim  as  gouty  a  case 
in  which,  without  articular  deposit,  always  supposing  this  to 
have  been  widely  sought,  interstitial  nephritis  and  other  lesions 
recognized  commonly  as  gouty  are  present,  and  in  which,  during 
life,  some  of  the  irregular  latent  or  incomplete  manifestations  of 
gout  have  been  observed.  If,  in  addition  to  this,  there  be  found 
history  of  gouty  ancestors  or  of  gouty  family,  I  maintain  that  it 
is  not  unwarrantable  from  this  and  the  clinical  features  of  the 
case  to  declare  for  gouty  disease  in  such  an  individual. 

Hence,  without  falling  back   on  uncertainty,   or   making  less 


54  PATHOGENY    OF    GOUT. 

sharp  the  line  of  demarcation  between  gout  and  other  joint- 
affections,  I  think  too  much  stress  has  been  laid  on  the  fact  of 
uratic  deposit  as  the  absolute  touch-stone  in  the  exact  diagnosis. 
My  belief  is  that  there  is  much  gouty  disease — incomplete  gout — 
as  well  as  much  overt  gout,  and  I  also  incline  to  think  that  this 
is  now  thrown  open  to  recognition  by  better  differentiation  of 
cases  and  improved  diagnosis.  It  may  also  be  the  case  that,  at 
the  present  time,  there  are  more  frequently  to  be  found  some  of 
these  modifications  of  that  more  classical  and  overt  disease  which 
was  described  by  most  of  our  predecessors  in  Medicine  who  wrote 
about  gout. 

I  may  state  that  these  views  are  held  in  the  French  school  by 
Charcot  and  Lanc^reaux,  and  they  find  support  from  Virchow  and 
Ebstein  in  Germany.  I  lay  stress  on  cases  of  chronic  and  in- 
complete gout,  in  elderly  women  more  especially,  where,  with 
many  truly  gouty  manifestations,  articular  changes  take  place 
leading  to  deformity,  nodes,  deflections  and  synostosis  of  phalanges. 
In  such  instances  the  kidneys  may  be  found  granular,  and  no 
uratic  deposits  be  detected.  The  synostosis  alone  would  afford 
to  my  mind  the  key-note  of  true  gouty  process.  The  clinical 
features  of  the  case  and  the  granular  kidneys  afford  strong 
additional  evidence.  The  absence  of  uratic  incrustation  may  be 
explained  by  the  incomplete  development  of  the  dyscrasia,  and 
by  insufficient  production  of  urates  to  allow  of  deposit.  Many 
observers  would  be  content  to  call  these  changes  "  rheumatic  "  or 
"  rheumatoid,"  but  I  must  deny  this  element  as  the  predominating 
factor,  for  the  reasons  just  given.  Morbid  anatomy  by  itself  is 
often  apt  to  mislead,  unless  supported  by  previous  and  careful 
clinical  study. 

The  latest  researches  into  the  nature  of  gouty  disease  as  a 
whole  plainly  point  to  the  very  wide-spread  character  of  the  dis- 
order. In  its  articular,  abarticular,  and  visceral  varieties  may 
be  found  ample  proof  of  this.  There  would  appear  to  be  no  im- 
munity from  gouty  processes  in  any  tissue  of  the  body. 

A  study  of  the  disease  as  met  with  only  in  hospital  practice  is 
insufficient  to  furnish  a  complete  experience  of  many  of  the  most 
varied,  if  peculiar,  characters  of  the  disorder.  These  are,  how- 
ever, to  be  found  abundantly  amongst  the  upper  classes  of  society, 
and  private  practice  alone  supplies  the  fullest  materials  for  their 
observation.  Many  of  the  descriptions  of  the  text-books  are  in- 
adequate to  portray  the  multiform  features  of  gouty  disease,  and 
it  may  be  that  this  arises  in   some   measure  from  a  necessarily 


SYDENHAM S    THEORY.  55 

incomplete   study  of  its    manifestations,   as    observed   mainly   in 
hospital  practice,  and  consequently  for  short  periods  of  time. 

Note. — It  must  be  acknowledged  that  such  light  as  modern  knowledge 
enables  us  to  throw  on  the  general  pathogeny  of  gout  does  not  place  us  very- 
far  in  advance  of  that  held  and  taught  by  many  writers  of  the  last  two  centuries. 
"We  now,  as  formerly,  invoke  both  humoral  and  nervous  causation.  The  same 
ideas  were  really  expressed,  in  the  thoughts  and  language  of  the  time,  by 
Sydenham,  the  author  of  one  of  the  most  concise  and  classical  treatises  on  the 
whole  subject  of  gout,  and  himself  a  martyr  for  many  years  to  the  malady. 
He  writes  :  "  The  more  closely  I  have  thought  upon  gout,  the  more  I  have 
referred  it  to  indigestion,  or  to  the  impaired  concoction  of  matters  both  in  the  farts 
and  juices  of  the  body."  This  is  an  expression  of  humoral  doctrine.  Intemper- 
ance in  food  and  drink  is  shown  to  impair  digestion  and  lead  to  oppression  ot 
the  system  by  a  mass  of  humours.  Next,  for  the  nervous  part  of  the  patho- 
geny :  "At  one  and  the  same  time  the  energy  of  the  spirits,  which  are  the 
instruments  of  digestion,  is  diminished." l  "  The  viscera  are  overworked,  and 
then  the  spirits,  which  have  been  long  giving  way,  are  prostrated.  If  it  were 
not  so,  if  it  were  a  simple  weakness  of  the  spirits,  children  and  women  and 
the  victims  of  long  illnesses  could  be  equally  gouty.  On  the  contrary,  how- 
ever, it  is  the  hearty  and  robust.  These  it  attacks  only  during  the  decline  of 
their  best  and  natural  spirits.  When  this  takes  place,  a  congestion  of  the 
humours  supervenes.  From  the  two  together  the  due  concoctions  are  vitiated  and 
prevented."  For  "  energy  of  the  spirits  "  we  are  to  understand,  in  the  thought 
and  language  of  to-day,  nervous  energy.  Sydenham  here  foreshadowed  what 
we  should  now'term  the  failure  of  tissue-metabolism,  induced  by,  or  associated 
with,  impaired  neuro-trophic  energy,  and  took  account  for  the  production  of 
gout  of  the  two  pathogenic  factors  of  "  peccant  matter  "  and  misdirected  or  per- 
verted nerve-force.     (The  italics  are  mine.) 

Again,  in  respect  of  the  paroxysmal  attack,  he  describes  the  vicious  humours 
as  increasing  in  bulk  and  virulence  till  "  Nature  "  can  no  longer  regulate  them, 
and  they  break  out,  fall  upon  the  joints,  &c.  "We  may  venture  to  interpret 
"  Nature  "  here  to  mean  the  neuro-trophic  equilibrium  of  the  system,  which  is 
thus  upset. 

Sydenham's  conceptions  appear  in  the  light  of  to-day  to  be  vastly  nearer  the 
truth  than  those  of  Cullen,  who  died  a  century  after  him.  Stahl,  from  whom 
the  latter  drew  his  too  purely  nervous  theories,  was  just  coming  into  note  at 
the  time  of  Sydenham's  death,  but  had  not  yet  published,  or  perhaps  formu- 
lated, his  views.  With  Trousseau  I  would  say,  "  Take  it  all  in  all,  the  theory 
of  the  great  English  physician  is  much  more  medical  than  the  theories  of 
modern  chemists."  I  therefore  claim  the  authority  of  Sydenham  in  support 
of  a  neuro-humoral  pathogeny  for  gout. 

1  R.  G.  Latham's  translation  of  Greenhill's  edition  of  Sydenham's  Works.  Syd. 
Soc.     London,  1850. 


CHAPTER  IV. 

THE  MORBID  ANATOMY  OP  GOUT. 

"  Though  the  terms  arthritis  and  podagra  would  seem  to  limit  the  malady  to  the 
feet  and  the  joints,  we  have  seen  it  in  almost  every  part  of  the  human  system." — Sir 
Henry  Halford,  Bart.1 

I. — Articular. 

In  treating  of  the  morbid  anatomy  of  a  particular  disease,  the 
physician  may  be  pardoned  if  he  refuses  to  accept  as  all-explana- 
tory of  antecedent  clinical  symptoms  the  teachings  it  may  offer. 
While  acknowledging  to  the  full  the  imperative  necessity  of 
daily  dead-house  study  for  the  practical  physician,  it  must  not 
be  forgotten  that  autopsies  often  fail  to  reveal  the  whole  truth  in 
respect  of  the  symptoms  and  features  of  disease  as  met  with 
during  life.  Slight  reflection  forces  us  to  concede  this.  As 
physicians,  we  have  to  deal  with  disease  in  the  living,  and  not 
in  the  dead  body,  and  thus  have  to  contend  with,  and  seek  to 
modify,  a  whole  realm  of  forces  that  cease  with  life.  Our  work 
relates  therefore  to  living  morbid  anatomy,  and  not  to  the  text- 
ures and  fluids  of  the  corpse.  We  have  to  seek  knowledge  of 
these  perversions  and  distempers  during  life,  and  to  try  to  gauge 
their  degree,  while,  perchance,  something  may  be  done  to  influence 
them  for  good,  and  so  promote  relief  or  recovery. 

The  physician  should  tell  of  the  physiological  disturbances 
which  are  induced  by  disease,  while  the  morbid  anatomist  should 
complement  his  story  by  demonstrating  the  textural  ravages, 
coarse  and  fine,  wrought  by  it. 

The  latter  may,  and  sometimes  does,  discover  changes  in  parts, 
which,  although  apparently  exactly  similar,  have  been  brought 
about  by  very  different  morbid  processes.  Of  these  he  can  give 
no  certain  account,  because  the  clinical  facts  are  wanting.  The 
physician  supplies  these,  and,  thus,  only  is  the  whole  truth  of  the 

1  On  the  Treatment  of  Gout,  Essays  and  Orations,  1 83 1. 


GOUTY    CHANGES    WIDELY    SPREAD.  57 

particular  case  likely  to  be  learned.  For  anything  approaching 
to  the  truth  the  labours  of  both  are  required.  In  the  case  of 
certain  organs  which  are  affected  with  gouty  disorders,  as,  for 
example,  the  eye  and  ear,  it  is  manifestly  difficult  to  secure  facts 
relating  to  morbid  anatomy.  There  is  much,  too,  in  gout  which 
is  clinical,  and  not  always  susceptible  of  post-mortem  proof. 

In  discussing  the  morbid  anatomy  of  gout,  it  is  incumbent  to 
point  out  that,  at  least,  two  divisions  of  this  large  subject  may  be 
made.  We  have  to  deal  in  practice  with  gout  that  is  primarily 
or  mainly  articular,  and  with  gout  or  gouty  disorders  that  are 
more  general,  and  certainly  less  localized,  in  the  joints.  The 
former  is  the  more  common  of  the  two.  Cases  exemplifying  both 
forms  are  not  infrequent.  With  some  exceptions,  it  may  be 
affirmed  that  primary  articular  gout  is  the  less  grave  form  of  the 
malady,  and  admits  of  more  satisfactory  prognosis  as  regards 
longevity. 

The  morbid  anatomy  of  gout  relates  to  almost  every  tissue  of 
the  body.  In  cases  of  lesser  degree,  it  may  be  affirmed  that  the 
changes  are  mainly,  if  not  entirely,  imposed  on  the  articular 
textures.  In  cases  of  profound  extent,  where,  in  fact,  the  body 
is  impregnated  with  gout("totum  corpus  est  podagra"  of  Syden- 
ham), it  is  hard  to  find  an  organ  or  texture  which  is  not  vari- 
ously impressed  and  changed  in  respect  of  its  intimate  structure 
as  the  result  of  the  disease. 

The  touch-stone  of  gout  being,  according  to  most  authorities, 
uratic  deposition,  it  has  been  well-established  that  if  in  any  part 
we  meet  with  this,  we  are  in  the  presence  of  unequivocal  gout. 
The  question  arises,  further,  whether  this  is  the  sole  manifesta- 
tion in  any  given  part.  Now,  deposits  of  urates  may  be  regarded, 
for  all  practical  purposes,  as  limited  to  but  a  few  of  the  tissues  of 
the  body.  The  joints  and  the  parts  around  and  in  connection  with 
them  are  the  chief  sites  of  deposition.  The  evidence  from  morbid 
anatomy  is  sufficient  to  justify  the  belief  that  deposition  is  favoured 
by  absence  of  vascular  activity,  and  by  the  consistency  and  pecu- 
liar nutritional  properties  of  the  texture  involved.  Wherever  the 
circulation  is  active  and  warmth  constant,  deposition  is  either 
impossible  or  greatly  resisted  With  failing  activity  of  circula- 
tion, and  consequent  degenerative  changes,  almost  any  tissue  may 
become  the  site  of  deposition.  Hence,  in  gouty  cachexia,  deposits 
increase  and  become  more  and  more  widely  spread  ;  and  hence, 
too,  an  originally  good  constitution,  and  the  vigorous  circulation 
which  accompanies  it,  both  render  the  vessels  less  prone  to  decay, 
and  the  tissues  better  able  to  resist  gouty  degenerative  and  deposi- 


58  MORBID    ANATOMY    OF    GOUT. 

tive  changes.  So  much  for  the  personal  tissue-potentiality,  which 
must  be  regarded  in  each  case  as  it  comes  before  us,  and  which 
goes  far  to  explain  many  of  the  perplexing  features  of  gout — as, 
for  example,  why  this  one  has,  and  this  one  has  not,  deposit ;  and 
why,  again,  another  is  a  prey  to  prodigious  deposition.  We  are, 
perhaps,  too  apt  to  regard  individuals  as  possessing  identical  pro- 
clivities, and  as  equally  prone  to  manifest  the  same  symptoms 
and  reactions  under  similar  provocations,  whereas  the  degree  of 
vulnerability  is,  in  truth,  most  varied,  and  is  affected  by  nume- 
rous inhibitory  influences  derived  from  mixed  diatheses,  blended 
strains,  and  tissue-peculiarities.  These  views  apply  not  only  to 
gouty,  but  to  any  morbid  tendency,  inherited  or  acquired,  and  I 
regard  them  as  essential  to  be  borne  in  mind,  and  very  helpful 
in  daily  practice. 

It  has  been  taught  that  rheumatism  attacks  the  larger  joints, 
and  gout  the  smaller.  It  would  not  be  safe  to  dogmatize  thus. 
With  the  exception  of  the  hip-joint,  which  is  rarely  affected,  it  may 
be  affirmed  that  gout  commonly  attacks  both  large  and  small  joints. 

The  order  of  invasion  of  tissues  by  uratic  deposits  is  fairly 
constant.  Thus,  diarthrodial  cartilages  are  the  first  to  be  affected, 
then  the  ligaments,  tendons,  and  bursas.  Next,  the  connective 
tissue  and  skin  become  impregnated.  The  order  of  invasion  of 
joints  is  also  often  constant,  beginning  with  the  great-toe,  meta- 
carpo-  and  metatarso-phalangeal  joints,  the  tarsus  and  carpus,  and, 
lastly,  the  larger  joints  with  no  constancy. 

The  appearance  of  articular  cartilage  in  which  simple  deposit 
of  urates  has  taken  place  exactly  resembles  that  which  would 
result  from  smearing  or  splashing  the  surface  with  fresh  white 
paint.  If  no  secondary  irritative  changes  have  occurred,  the 
surface  is  quite  smooth,  and  the  synovial  fluid  is  natural 
in  amount  and  consistence.  This  white,  plastered,  surface  is 
sometimes  singularly  even  and  uniform,  covering  exactly  the 
limits  of  all  the  cartilages  forming  the  interior  of  a  joint.  This 
may  exist  without  any  signs  of  erosion  or  ulceration,  and  without 
any  irritative  overgrowth  in  its  vicinity.  There  are  examples  of 
this  in  the  Museum  of  St.  Bartholomew's  Hospital.  Many  joints 
in  a  body  may  be  thus  encrusted.  Such  specimens  retain  their 
appearance  unchanged  for  many  years.  We  have  two  in  the 
Museum  which  Mr.  Stanley  placed  there,  and  after  seventy  years' 
immersion  in  pure  spirit 1  they  are  now  quite  exemplary.      These 

1  Methylated  spirit  was  not  used  till  within  the  last  twenty-five  years. 
It  is  important  to  note  that  prolonged  immersion  in  methylated  spirit  is  apt  to 
cause  complete  removal  of  uratic  deposit  from  cartilage.     This  is  apparently  due  to 


URATIC   ARTHRITIS,    ITS    NATURE.  59 

specimens  were  originally  described  as  encrusted  with  carbonate 
of  lime,  and  Scudamore  in  his  book  so  described  them  in  181  3. 
In  1884  I  had  them  dismounted  and  re-examined,  both  chemi- 
cally and  microscopically,  and  on  analysis  they  were  found  to 
present  all  the  characters  of  gout  with  sodium  urate  deposit,  cal- 
cium salts  being  present  only  in  appreciable  amount.  Dr.  Fuller 
referred  to  these  specimens  in  his  book  on  "  Rheumatism,  Rheu- 
matic Gout,  and  Sciatica  "  (1852),  and  considered  them  as  illus- 
trative of  a  hybrid  case  of  rheumatism  and  gout.  Few  would  now 
be  found  to  believe  that  these  were  other  than  examples  of  true 
gouty  (uratic)  arthritis.1 

Instances  such  as  these  indicate  that  abundant  uratic  deposits 
may  occur  in  joints  without  exciting  irritating  overgrowth.  Why 
this  should  happen  in  some  cases  and  not  in  others,  it  is  hard  to 
explain.  Some  personal  factor  or  tissue-peculiarity  may  account 
for  it.  It  has  already  been  stated  that  deposits  occur,  sometimes 
to  enormous  extent,  without  exciting  even  pain,  although  the 
deformities  thus  induced  are  prodigious.  This  is  termed  quiet 
deposit.2  It  is  certain  that  the  bulkiest  deposits  occur  in  the 
upper  rather  than  the  lower  extremities. 

The  changes  in  articular  cartilages  which  result  from  gout  have 
not  been  studied  so  carefully  as  they  deserve.  As  a  matter  of  fact, 
the  joints  have  only  of  late  years  been  inspected  in  necropsies  of 
gouty  subjects,  and  attention  has  been  mainly  directed  to  the 
question  of  uratic  deposits. 

Study  of  museum  specimens  shows  that  profound  changes  may 
occur  in  all  the  structures  of  gouty  joints.  So  much  so  is  this 
the  case,  that  some  observers  have  come  to  regard  these  as  indi- 
cating the    coexistence,    or   even   the    coalescence,   of  rheumatic 

some  special  solvent — possibly  an  acid — in  certain  kinds  of  methylated  spirit.  Pure 
spirit  of  wine  has  no  such  action.  Thus,  within  two  years  a  large  series  of  speci- 
mens, illustrating  uratic  arthritis,  put  up  by  Dr.  Norman  Moore,  became  practically 
valueless  as  indicating  the  truly  gouty  nature  of  the  cases  they  came  from,  whereas 
specimens  in  our  Museum  put  up  many  years  ago  in  pure  spirit  are  as  valuable  now 
as  when  fresh.  Museum  specimens  may  thus  become  a  source  of  perplexity  and 
error  to  the  students  of  the  future.  Mr.  Stanley's  specimen,  already  referred  to, 
was  put  up  in  pure  spirit,  which  was  always  used  in  museums  at  that  time. 

Mr.  Shattock  tells  me  that  this  untoward  effect  on  encrusted  parts  may  be  pre- 
vented by  dissolving  urate  of  sodium  in  methylated  spirit.  Tophi  may  be  macerated 
in  the  preserving  spirit,  and  after  filtration  this  tincture  or  solution  may  be  employed 
for  encrusted  specimens  in  museum  collections,  and  prove  trustworthy  as  a  preserva- 
tive of  the  characteristic  features. 

1  Vide  Notes  respecting  two  Old  Specimens  of  Gouty  Arthritis  in  the  Hospital 
Museum.     St.  Earth.  Hosp.  Reports,  vol.  xx.,  1884. 

2  Drs.  Moxon  and  Pye- Smith  have  noted  the  occurrence  of  slow  deposition  of  urates 
in  joints  without  symptoms.     Fagge's  Prin.  and  Pract.  of  Physic,  vol.  ii.  p.  801. 


6d         morbid  anatomy  of  gout. 

changes.  Hence,  Mr.  Hutchinson  regards  it  as  rare  to  meet  with 
joints  presenting  only  the  characteristic  deposit,  and  believes  that 
all  the  associated  tissue-changes  are  rheumatic,  and  thus  he  argues 
for  a  true  "  rheumatic- gout "  as  the  outcome  of  all  gross  changes 
in  such  cases. 

I  cannot  agree  with  him  on  this  point.  It  is  certain  that  very- 
few  specimens  exist  showing  well-marked  changes  of  chronic 
rheumatic  or  osteo-arthritis  together  with  uratic  deposits.  Such 
specimens  must  be  accepted  as  illustrating  a  true  coincidence  or 
a  coalescence  of  two  morbid  conditions,  and  I  see  no  reason  for 
doubting  that  chronic  rheumatic  arthritis  and  true  gout  may  co- 
exist and  blend  in  the  same  individual.  It  would  be  strange  if 
this  did  not  sometimes  happen  ;  but  as  a  matter  of  observation,  it 
is  rare  to  find  such  a  conjunction.  Mr.  Hutchinson's  views  are 
so  dogmatically  set  down  on  this  point,  and  his  opinions  very 
justly  carry  so  much  weight,  that  I  am  concerned  to  combat  them 
as  forcibly  as  I  can.  He  holds,  with  Charcot,  that  rheumatism 
and  gout  are  the  outcome  of  a  basic  arthritic  diathesis,  and  thinks 
it  a  matter  of  habit,  of  dietetics,  or  of  exposure  to  damp  and  cold, 
as  to  whether  one  or  other,  or  both,  of  these  troubles  shall  develop 
in  any  individual  who  inherits  this  diathesis.  "  Gout,"  he  thinks, 
"  is  but  rarely  of  pure  breed,  and  often  a  complication  of  rheu- 
matism. It  so  often  mixes  itself  up  with  rheumatism,  and  the 
two  in  hereditary  transmission  become  so  intimately  united,  that 
it  is  a  matter  of  considerable  difficulty  to  ascertain  how  far  rheu- 
matism pure  can  go.  .  .  .  When  this  complication  exists,  it  shows 
its  power,  we  may  suspect,  by  inducing  a  permanent  modifica- 
tion of  tissue,  and  it  is  to  this  modification  that  the  peculiari- 
ties in  the  processes  (transitory  rheumatic  pains  in  joints,  fasciae, 
and  muscles,  chronic  crippling  arthritis,  destructive  arthritis  with 
eburnation,  lumbago,  sciatica,)  are  due.  Hence,  the  impossibility, 
under  many  conditions,  of  discriminating  between  gout  and  rheu- 
matism." x 

The  evidence  that  is  to  settle  this  vexed  question  is  as  yet  not 
all  forthcoming.  The  sources  of  this  evidence  are  obviously  three- 
fold :  first,  the  antecedent  history;  secondly,  the  clinical  symptoms  ; 
and  thirdly,  the  morbid  anatomy.  Now,  the  difficulties  in  the 
way  of  getting  a  trustworthy  antecedent  history  are  enormous, 
and  this  holds  good  almost  equally  in  every  rank  of  life.  It  has 
been  my  habit  to  seek  for  this  evidence  untiringly  in  all  my  cases, 
and  the  results  are  for  the  most  part  unsatisfactory.  Still,  with 
care,  it  is  possible  in  many  instances  to  unravel  the  family  and 
1  Pedigree  of  Disease,  1883,  p.  126. 


NUTRITION    OF    ARTICULAR    CARTILAGE.  6l 

personal  histories  so  as  to  allow  the  fact  of  goutiness  to  be  either 
admitted  or  rejected.  Failing  the  history,  recourse  must  be  had 
to  study  of  the  existing  clinical  symptoms  and  the  effects  of  treat- 
ment. The  latter,  in  particular,  seldom  fail  to  throw  light  on  the 
nature  of  any  given  case.  The  ultimate  appeal  is  to  morbid 
anatomy.  Hitherto,  in  the  case  of  gout,  the  touch-stone  of  the 
process  has  been  the  presence  of  uratic  deposit.  As  already 
stated,  Mr.  Hutchinson  regards  it  as  rare  to  meet  with  simple 
deposit  in  joints  apart  from  other  changes.  My  experience  is 
quite  otherwise,  so  that  I  regard  this  as  a  common  occurrence, 
without  any  associated  structural  changes.  The  gross  lesions 
referred  to  by  Mr.  Hutchinson  as  due  to  rheumatic  influence,  I 
believe  to  be  the  result  of  gouty  arthritis,  and  I  should  require 
strong  evidence  to  convince  myself  to  the  contrary.  In  a  case 
presenting  other  truly  gouty  characteristics,  I  am  not  prepared  to 
insist  on  the  necessity  of  discovering  deposited  urates  in  every 
joint,  since  I  believe  that,  as  a  result  of  urichaemia,  many  and 
varied  textural  lesions  may  occur  without  such  deposit,  and  I  am 
not  alone  in  this  opinion.  The  variety  of  cartilage  which  is 
chiefly  involved  in  gouty  processes  is  that  known  as  articular  or 
hyaline  cartilage.  This  has  a  transparent  ground-glass-like  basis. 
The  cells  are  spherical  or  oval,  with  a  single  nucleus,  and  are 
usually  arranged  in  pairs  contained  in  a  single  capsule.  In  the 
neighbourhood  of  the  bone  the  capsules  contain  more  than  two 
cells. 

With  respect  to  the  mechanism  of  cartilage -nutrition,  reference 
may  be  made  to  Dr.  Albert  Carter's  observations  on  the  diaplas- 
matic  system  of  vessels  which  he  believes  to  exist  in  non- vascu- 
lar parts.  He  found  in  articular  cartilage  certain  reticulations 
(plasma  channels)  passing  from  the  margins  of  the  lacunas,  which 
were  filled  here  and  there  with  granules.1 

These  have  not  been  noted  by  other  observers,  From  conver- 
sations with  distinguished  anatomists  and  histologists,  I  gather 
that  there  is  at  the  present  time  no  certainly  demonstrated  me- 
chanism for  the  intimate  textural  nutrition  of  cartilage. 

Where  articular  cartilage  adjoins  the  synovial  membrane  and 
capsule  of  a  joint,  the  cells  are  branched,  and  pass  insensibly  into 
the  connective  tissue-cells  of  the  synovial  membrane. 

In  studying  the  morbid  articular  changes  due  to  gout,  it  has 
been  necessary  first  to  examine  the  diarthrodial  cartilages  in  per- 
sons at  various  ages  and  in  those  of  the  healthy.     Dr.  Wynne  and 

i  Professor  Turner  has  kindly  referred  me  to  this  paper.     Jour.  Anat.  and  Phys., 
vol.  iv.  p.  97,  1870. 


MORBID    ANATOMY    OF    GOUT. 


I  have  found  that  in  normal  adult  cartilage  three  zones  of  cells  are 
perceptible:  (Fig.  i) — (a.)  A  superficial  one  of  flattened  cells,  in 
section  short  spindles,  lying  parallel  to  the  surface  in  three  or  four 
layers ;  (&.)  a  middle  one  of  lacunae,  containing  one  or  two  cells, 
scattered  sparingly  through  the  matrix,  and  tending  to  lie  hori- 
zontally, parallel  as  they  approach  to  the  surface  ;   and  (c.)  a  deep 

zone  of  lacunas,  larger  and  more 
a  numerous  than  in  (b),  containing 
various  numbers  of  cells,  and 
lying  perpendicularly.  There  is 
no  layer  of  epithelial  cells  lining 
the  free  surface.  This  usualty 
h  disappears  early  in  life,  but  may 
be  found  in  adults  at  the  mar- 
gins, where  they  are  not  subject 
to  pressure. 

There  is  no  investment  of 
synovial  membrane  on  the  free 
surface  of  articular  cartilage. 
c  The  superficial  zone  is  beset  with 
spindle-shaped  cells  lying  in  a 
matrix,  which  at  the  periphery 
exhibits  a  transition  into  fibrous 
tissue,  continuous  with  that  of 
the  synovial  membrane. 

In  persons  not  the  subjects 
of  gout,  senile  changes  occur  : — 
(«.)  The  superficial  zone  of  flat 

Fig.  i.— Human  Articular  Cartilage,  from  head     cells  disappears;1    (&.)  the  Carti- 
of  a  metatarsal  bone  (Normal.)  £  L  i  •  r» 

lage-cells  may  proliferate,  so  that 
the  middle  and  deep  zones  become  indistinguishable ;  (c.)  the 
matrix  may  exhibit  fibrillation  (vide  Fig.  2)  ;  (cl.)  erosions  may 
occur,  which  may  even  lay  bare  the  bone. 

As  I  have  already  stated,  there  is  no  investment  of  synovial 
membrane  on  the  free  surface  of  articular  cartilage.  The  super- 
ficial zone  is  beset  with  spindle-shaped  cells  lying  in  a  matrix, 
which  presents  also  different  characters  from  that  in  other  portions 
of  the  texture.  Thus,  it  has  a  fibrous  aspect,  and  is  striated  hori- 
zontally for  about  one-sixth  of  the  depth  of  the  entire  cartilage. 

This  fibrous  appearance  is  sometimes  clearly  seen  in  sections 
where  fibres  are  seen  partly  detached  from  the  free  surface  in 

1  The  superficial  zone  of  flat  cells  has  been  found  in  the  cartilages  of  the  knee  in  a 
man  aged  sixty,  in  quite  a  normal  condition. 


RELATIONS    OF    URATKJ    DEPOSITS. 


6 


ribbon-like  bands.  The  round  cells  of  the  proximal  layer  become 
transformed  into  spindle-shaped  ones  towards  the  free  articular 
surface. 

The  mechanism  of  nutrition  of  articular  cartilage  is  still,  as  I 
have  stated,  a  moot-point  with  anatomists.  Aly  friend  and  former 
preceptor,  Professor  Sir  William  Turner,  of  Edinburgh,  is  in  the 
habit  of  teaching  that  "  the  encrusting  cartilage  of  diarthrodial 
joints  derives  its  nourishment  in  the  adult  partly  from  the  vessels 
of  the  periosteum  which  reach  its  periphery,  and  partly  from  those 
of  the  synovial  membrane,  which  not  only  reach  its  peripheral 
edge,  but  extend  for  a  very  short  distance  on  its  free  surface,  where 


Fig.  2. — Articular  Cartilage  (Great  Toe-Joint).  Encrusted  with,  sodium  urate,  which 
appears  black  by  reflected  light.  Fibrillation  of  matrix  and  proliferation  of 
cartilage-cells.  The  latter  changes  sometimes  occur  in  old  persons  independently 
of  gouty  influence. 


they  form  a  definite  vascular  border — the  "  cir cuius  articuli  vas- 
culosus."  Professor  Turner  denies  that  the  cartilage  is  nourished 
by  vessels  derived  from  the  sub-  or  superjacent  bones. 

Some  differences  of  opinion  exist  as  to  the  exact  relation  of 
uratic  deposit  to  the  several  elements  of  articular  cartilage.  This 
subject  has  been  carefully  studied  by  several  observers.  The  cells 
are  held  to  be  the  centres  of  primary  deposit  by  Cornil  and  Ean- 
vier,  by  Charcot  and  Rindfieisch,  and  are  believed  to  be  actively 
concerned  in  it.  William  Budd 1  also  conceived  that  there  was 
some  relation  between  the  deposit  and  the  cartilage-cells,  which 
he  regarded  as  the  original  foci  of  it.    He  remarked  that  "  needles 

1  W.  Budd,  Researches  on  Gout,  Med.-Chir:  Trans.,  vol.  xxxviii.,  1855. 


64  MORBID  ANATOMY  OF  GOUT. 

begin  to  radiate  from  these,  not  in  relation  to  any  cartilage-cells, 
but  to  the  whole  central  mass ;  hence,  the  dynamic  relations  (if 
any)  between  the  cell  and  the  deposit  are  superseded  by  the 
common  physical  influences  in  action  around  it." 

Other  observers  have  conceived  that  the  deposit  occurs  quite 
indiscriminately  and  irregularly.  It  is  naturally  a  matter  of  diffi- 
culty to  determine  the  truth  in  this  matter.  The  appearances 
afforded  by  study  of  sections  of  the  cartilage  so  infiltrated  justify 
the  opinion  that  this  deposit,  in  crystallizing,  pushes  its  way  with- 
out special  regard  to  the  component  elements  of  the  tissue,  and 
acts  in  respect  of  it  as  if  it  were  an  indifferent  or  homogeneous 
medium.  My  own  impression  is  that  the  deposit  progresses  indis- 
criminately throughout  the  elements  of  the  cartilage,  and  that  the 
cells  take  no  active  part  in  directing  or  determining  it. 

My  colleague,  Mr.  Bowlby,  supports  the  view  of  Ebstein  in 
respect  of  urates  being  only  deposited  in  cartilage  already 
damaged.  He  has  observed  that  the  articular  cartilage  is  gene- 
rally fibrillated  and  eroded.1  He  thinks  it  probable  that  some 
of  the  salt  may  be  formed  by  disintegration  of  the  cartilage  itself, 
and,  thus,  agrees  with  Cantani,2  who  regarded  the  uric  acid  dys- 
crasia  of  gout  as  due  to  disturbed  nutrition  of  this  and  of  other 
tissues  composing  the  joints,  and  with  Robin,3  who  holds  that 
gelatinous  structures  may  disintegrate  into  uric  acid.  I  admit 
the  possibility  of  such  a  transformation,  but  I  do  not  accept  this 
explanation  of  ordinary  uratic  deposits. 

In  respect  of  uratic  encrustation  of  articular  cartilage,  it  is  to 
be  noted  that  post-mortem  evidence  points  to  involvement  in  this 
fashion  of  joints  which  have  not  been  during  life  the  seat  of  overt 
gouty  attacks.  In  studying  joints  which  are  infiltrated  in  an 
early  stage  or  in  a  lesser  degree,  it  is  observable,  with  some  con- 
stancy, that  the  cartilage  is  more  profoundly  affected  on  pro- 
minent and  central  portions.  Two  reasons  have  been  assigned 
for  this.  One  is,  that  the  prominent  parts  are  those  on  which 
most  pressure  and  friction  are  exerted,  and  therefore  most  likely 
to  be  injured  and  faulty  in  structure;  and  the  other  is,  that  the 
cartilage  is  in- nearer  relation  to  nutrient  vessels  at  its  periphery, 
and  therefore  less  well-nourished  and  more  vulnerable  in  its 
central  portions.  It  is  almost  certain  that  uratic  deposit  is 
most  favoured  in  parts  which  are  least  vascular  and  warm,  and 
therefore  most  peripheral  or  distant  from  the  circulatory  centre. 

1  Surgical  Pathology,  p.  3 1 1,  1887. 

2  Quoted  by  Ebstein,  op.  cit. 

3  Dictionnaire  de  Med.,  1865. 


SITES    OF    UBATIC    DEPOSIT    IN    CARTILAGE.  65 

Ebstein  declares  that  lie  has  never  seen  urates  crystallize  in 
normal  tissues.     It  is  certain  that  such  deposits  have  been  found 

many  years  after  a  single  attack  of  acute  gout  has  occurred  in  a 
joint. 

The  changes  induced  by  gout  in  articular  cartilage  have  been 
referred  to  two  stages,  the  infiltrating  or  depositive  one,  and  the 
irritative  or  reactive  inflammatory  one.  Study  of  a  large  num- 
ber of  gouty  joints  does  not  appear  to  warrant  this  classifica- 
tion. It  seems  probable  that  both  changes  proceed  together  in 
many  instances,  and  it  is  certain  that  the  irritative  or  inflamma- 
tory stage  may  be  absent  so  far  as  overgrowths  or  gross  changes 
are  concerned.  Deposition  of  urates  may  continue  after  the 
irritative  action  has  begun.  It  has  been  urged  that  the  latter 
stage  is  akin  to  the  changes  of  chronic  rheumatic  arthritis  which 
simply  ensue  on  some  irritative  provocation,  humoral  or  neuro- 
trophic. 

I  am  not  prepared  to  deny  this  absolutely,  though  it  must  be 
allowed  that  such  irritative  changes  often  form  no  part  of  the 
gouty  process,  and  in  no  case  of  gout  do  they  ever  reach  the 
degree  of  development  found  in  rheumatic  or  rheumatoid  disease. 
I  must  again  remark,  that  identity  of  morbid  change  is  no  proof 
of  identity  of  the  exciting  cause  in  any  given  case.  The  same 
reasoning  is  applied  to  the  deflections  and  distortions  of  the  digits. 
This  I  accept,  for  these  changes  are  often  identical  in  gouty  and 
rheumatic  cases,  and  are  sometimes  entailed  by  the  pain,  but  more 
often  by  the  chronicity  of  the  processes,  however  induced,  in  the 
affected  joints. 

Uratic  deposit  is  not  always  found  in  the  superficial  layers 
of  articular  cartilage,  but  may  exist  on  the  under-surface  of 
the  cartilage,  which  is  often  swollen,  or  degenerated.  {Vide 
Plate,  Fig.  2.)  A  common  site  for  this  is  the  inter- condyloid 
space  of  the  femur. 

In  the  examination  of  many  sections  of  non- gouty  diarthrodial 
cartilage,  it  is  common  to  find  the  distal  layer  worn  away  in  adult 
or  advanced  life.  This  is  proved  by  the  absence  of  the  spindle- 
shaped  cells,  which  at  this  part  lie  horizontally,  or  parallel  to  the 
free  surface.  This  layer  is  well  seen  in  the  cartilages  of  the 
young.  The  lacunae  usually  found  at  the  free  surface  of  adult, 
or  of  gouty,  cartilage  are  more  or  less  round,  and  are  such  as 
occur  in  the  centre  of  this  structure  in  health,  forming  the  middle 
zone. 

With  the  able  assistance  of  my  present  senior  house-physician, 
Dr.  Wynne,  who  has  expended  much  time,  skill,  and  study  on  my 

E 


66 


MORBID  ANATOMY  OF  GOUT. 


behalf  in  respect  of  the  minute  anatomy  of  very  many  gouty 
joints,  the  following  points  have  been  determined  : — 

(i.)  That  the  most  frequent  site  of  deposit  is  at  the  surface, 
extending  about  A  inch  into  the  cartilage.      (Vide  Fig.  3.) 

(2.)  That,  as  a  rule,  the  deposit  has  no  special  relation  to  the 


Fig.  3. — Articular  Cartilage  encrusted  with  Sodium  Urate,  which  is  deposited  in 
the  usual  site  at  the  tree  margin  (knee). 

cells,  but  in  some  cases  the  crystals  of  sodium  urate  are  more 
numerous  in  and  around  the  cells.     (Vide  Fig.  4.) 

(3.)  A  less  common  site  is  in  the  deeper  layers  of  the  cartilage, 
starting  in  some  cases  from  the  bone.      (Vide  Plate,  Fig.  2.) 

In  respect  of  the  cartilage  : — 

(4.)  In  all  cases  the  superficial  zone  disappears. 


? 
i 


;J> 


Fig.  4. — Illustrating  Uratic  Deposition  in  Cartilage-capsules. 

(5.)  As  a  rule,  on  washing  out  urates,  no  change  is  found  in 
the  cartilage,  except  that  it  is  slightly  more  granular  than  else- 
where. An  appearance  is  sometimes  seen  as  if  the  cartilage  were 
fibrillated  in  the  direction  inwards  taken  by  the  penetrating- 
crystals,  but  we  have  never  been  quite  sure  whether  this  may  not 
have  been  due  to  insufficient  maceration,  and,  so,  dependent  on 
remains  of  crystals. 


CARTILAGE-CELLS    NOT    FOCI    OF    URATIC    DEPOSIT.        67 

(6.)  Treated  with  an  acid  (HC1),  destruction  of  cartilage  at  seat 
of  deposit  was  found,  but  appeared  not  to  be  due  to  the  deposi- 
tion, being  only  met  with  when  the  latter  was  very  abundant. 

(7.)  Quite  exceptionally,  an  appearance  of  a  funnel-shaped 
cavity,  as  figured  by  Ebstein,  and  described  by  him  as  necrotic, 
was  met  with  proceeding  inwards  from  the  free  surface.  This  is 
probably  not  indicative  of  necrosis,  because  no  signs  of  irritative 
change,  such  as  might  be  expected,  were  to  be  found  in  the 
immediate  neighbourhood.  The  appearance  may  be  accounted  for 
by  the  washing  out  of  the  urates,  which  in  these  situations  are 


Fig.  4A. 
(A.)  Showing  a  (?  necrotic)  patch,  as  described  by  Ebstein,  in  cartilage  from  gouty  knee-joint ; 
(B.)  Urates  partly  removed  by  distilled  water.     (This  appearance  was  not  present  in  all 
the  sections  examined,  and  only  occurred  where  the  uratic  deposit  was  dense). 

abundant,  causing  the  involved  matrix  to  crumble  away,  owing  to 
failure  of  support. 

Our  general  conclusions,  therefore,  are  that  there  is  no  special 
microscopical  condition  of  cartilage  peculiar  to  gouty  deposit ;  that 
the  common  site  of  deposit  is  at  the  free  surface,  but  that  it  may 
occur  at  any  point,  and  that  the  cells  are  not  foci  of  deposition. 

Although  uratic  deposition  may  occur  in  any  tissue  during  life, 
its  most  frequent  site  post-mortem  is  in  the  cartilages,  because 
means  for  its  removal  are  there  least  efficient.1 

1  The  encrustations  are  always,  in  my  experience,  formed  by  urates  in  slightly 
curved  needles,  sometimes  lying  parallel,  or  radiating  outwards.  In  the  cells  they 
are  prone  to  form  tufts,  which  bristle  with  needles  like  teasel-burrs.  ( Vide  Figs.  3 
and  4.) 

According  to  Dr.  Ord,  this  acicular  form  of  crystallization  should  not  occur  in  the 
substance  of  a  colloid  substance  such  as  cartilage,  and  he  thinks  a  spheroidal  form  is 
what  might  naturally  be  expected  in  such  a  texture.  He  remarks  :  "  It  may  be 
assumed  that  the  needles  are  to  be  regarded  as  crystals,  though  their  appearance 
of  flexibility,  their  remarkable  tenuity,  and  the  absence  from  them  of  angularity  of 


68  MORBID  ANATOMY  OF  GOUT. 

Uratic  deposit  is  not  always  found  as  an  enduring  evidence  of 
the  existence  of  past  attacks  of  gout  in  a  joint.  Garrod  has 
affirmed  this  to  be  the  case.  The  following  case  may  be  cited 
in  proof  of  the  contrary.  A  man,  get.  forty-three,  was  under  my 
care  suffering  from  chronic  pulmonary  phthisis  and  interstitial 
nephritis.  He  was  a  brassfounder,  and  had  used  lead.  There 
was  no  blue  line  on  his  gums.  He  had  drunk  freely  of  beer.  He 
died  of  acute  bronchitis.  He  had  had  two  attacks  of  gout  in  the 
right  great  toe-joint.  At  the  autopsy  neither  toe-joint  contained 
a  speck  of  uratic  deposit.  The  kidneys  were  large,  granular,  and 
cystic,  but  free  from  uratic  streaks. 

Attention  has  not,  so  far  as  I  know,  been  sufficiently  directed 
to  the  frequent  occurrence  of  abrasion  and  ulceration  of  articular 
cartilage  in  gouty  joints.  In  many  instances  this  is  to  be  seen, 
and  with  especial  frequency,  perhaps,  in  the  knee-joint.  Common 
sites  for  this  are  the  patella  and  the  inter-condyloid  notch  of  the 
femur.  The  eroded  patch  may  be  not  more  than  a  fourth  of  an 
inch  in  diameter,  and  seldom  exceeds  an  eighth  of  an  inch  in 
depth.  The  cartilage  appears  worn  away  at  the  margins,  and 
ulcerated  to  the  bone  at  the  centre  of  the  patch,  where  vascularity 
and  even  bloody  effusion  may  be  found,  arising  from  granulations 
of  subjacent  bone.  No  urates  are  usually  seen  in  the  vicinity  of 
these  ulcerations.  They  are  so  frequent  as  to  impress  one  with 
the  belief  that  they  form  part  of  the  morbid  articular  process 
apart  from  mere  uratic  encrustation,  and,  so  far,  they  support  the 
views  of  Ebstein  already  alluded  to.1  These  points  are  not  to 
be  confounded  with  the  grooved  lines  of  erosion  met  with  in 
chronic  rheumatic  arthritis,  but  they  are  significant  of  irritative 
change. 

In  the  great  toe-joint,  erosions  are  met  with  not  infrequently, 
and  in  this  situation  such  changes  are  common  as  a  result  either 

section  are  departures  from  the  typical  qualities  of  the  crystal.  They  are  to  my 
mind  crystals  with  definite  colloidal  affinities."  *  Again,  "  The  needle,  though  a  crys- 
talline form,  is  not  by  any  means  the  true  or  perfect  crystalline  form  of  urate  of 
soda.  The  true  form  is  a  short,  six-sided  prism.  The  needle  of  urate  of  soda  occurs 
where  uric  acid  would  be  found  in  spheres,  and  urate  of  ammonia  in  molecules.  But 
it  also  occurs  where  uric  acid  would  be  in  crystals — that  is  to  say,  where  no  colloid 
save  colloidal  manifestations  of  itself  exists." 

1  It  is  only  right,  however,  to  state  that  such  erosions  are  not  very  infrequent  in 
the  same  situations  in  joints  of  persons  who  present  no  overt  signs  of  gout.  In  the 
dead-house  at  St.  Bartholomew's  the  joints  of  a  large  proportion  of  the  cases  are 
regularly  examined.  Erosions  are,  however,  more  frequent  in  gouty  than  in  non- 
gouty  joints. 

*  On  the  Influence  of  Colloids  upon  Crystalline  Form,  W.  M.  Ord,  M.D.,  1879, 
p.  67. 


NORMAN    MOORE'S    OBSERVATIONS    ON    GOUTY    JOINTS.      69 

of  old  injuries,  or  of  premature  decay  of  the  cartilage.  As  these 
erosions  are  found  in  middle  life,  they  must  be  classed  either  as 
prematurely  senile  changes,  or  as  specifically  gouty. 

In  an  elaborate  and  very  valuable  contribution  to  the  Morbid 
Anatomy  of  Gout  by  my  colleague,  Dr.  Norman  Moore,1  the  fol- 
lowing are  some  of  the  conclusions  arrived  at  in  respect  of  the 
changes  in  joints,  derived  from  study  of  eighty  cases : — 

1.  That  degenerative  changes  are  usually  present  in  the  same 
joint,  or  in  other  joints  of  the  same  body,  or  in  both,  where  urate 
is  present  even  in  a  single  joint. 

2.  That  deposits  of  urate  of  soda,  like  other  degenerative 
changes,  are  usually  more  or  less  symmetrically  arranged  on  both 
sides  of  the  body. 

3.  That  it  is  commoner  to  find  a  deposit  in  the  joints  of  the 
legs  than  of  the  arms. 

4.  That  a  deposit  may  be  present  in  nearly  all  the  joints  of 
the  lower  limbs,  and  absent  from  those  of  the  upper  limbs. 

5.  That  a  deposit  is  commoner  in  the  metatarso-phalangeal 
joint  of  the  great-toe  than  in  the  phalangeal  joint. 

6.  That  however  abundant  in  and  below  the  knees,  a  deposit 
is  rare  in  the  hip-joint. 

7.  That  a  deposit  is  often  found  in  the  great-toes  and  knees 
when  absent  in  the  ankles,  but  not  in  the  ankles,  when  absent  in 
the  toes  and  knees. 

8.  That  when  present  in  the  ankles,  some  deposits  may  be 
usually  found  in  the  ligaments  of  the  foot. 

9.  That  the  elbow-joint  has  deposit  when  one  is  present  in 
the  wrist. 

10.  That  the  sterno-clavicular  joint  rarely  contains  deposit. 

1 1 .  That  the  articulations  of  the  larynx  rarely  contain  deposit. 
Dr.    Moore   found   that   extensive   deposit   may   exist   in   the 

articular  cartilages  without  any  external  deposit,  such  as  tophi  in 
the  ear,  and  that  it  is  comparatively  rare  for  the  latter  to  be  pre- 
sent in  such  cases.  It  is,  further,  to  be  noted  that  urates  may  be 
absent  from  the  interior  of  nodular  joints,  while  specks  of  them 
may  be  found  externally  in  their  ligaments  and  adjacent  tendons. 
The  immunity  of  the  hip-joint  is  remarkable.  Garrod  re- 
cords a  case  and  depicts  the  appearances  in  a  man,  set.  fifty- 
four,  where  deposit  occurred  on  the  head  of  the  femur,  in  the 
acetabulum,  and  in  the  ligamentum  teres.  In  chronic  rheumatic 
arthritis  the  hip-joint  is  especially  liable  to  be  involved,  such 
cases  being  often  termed  "hip-gout."      In  these  there  may  be 

1  St.  Earth.  Hosp.  Reports,  vol.  xxiii.,  1887. 


yo  MORBID  ANATOMY  OF  GOUT. 

profound  bony  changes  following  on  absorption  of  the  cartilages, 
with  permanent  crippling  as  a  result. 

The  shoulder-joint  is  singularly  free  from  uratic  deposit  or 
gouty  changes. 

The  order  of  frequency  of  uratic  deposit  in  the  knee  is,  accord- 
ing to  Dr.  Moore,  the  articular  surface  of  the  patella,  inter-condy- 
loid  groove  of  femur,  condyles,  and  lastly,  the  surface  of  the  tibia. 

Ebstein  maintains  that  deposits  occur  chiefly  in  parts  where 
tissue-change  is  least  active,  and  where  the  conditions  for  separa- 
tion from  nutrient  fluids  are,  thus,  most  favourable.  By  direct 
experiment  he  proved  that  uric  acid  has  a  highly  injurious  effect 
on  certain  tissues,  and  especially  upon  the  cornea. 

Deposits  occur  in  the  marrow  of  bone,  usually,  but  not  always, 
in  the  neighbourhood  of  encrusted  cartilages,  and  they  sometimes 
appear  to  be  due  to  direct  destruction  of  the  bony  lamina  by 
the  continued  pressure  of  intra-articular  accumulations.1  {Vide 
Plate,  Fig.  2.)  Cases  are,  however,  met  with  where  the  articular 
cartilage  is  intact,  and  yet  deposit  has  occurred  in  the  bone.  In 
the  Museum  of  St.  Bartholomew's  Hospital  are  several  specimens 
illustrating  this.  Dr.  Wilks  found  in  a  man,  aet.  forty-six,  who 
had  suffered  for  sixteen  years  from  gout,  and  had  tophi  round 
the  digital  joints,  uratic  deposit  in  the  centre  of  the  first  phalanx 
of  the  ring-finger.  This  finger  was  amputated  by  Mr.  Bryant 
for  pain  caused  by  disorganization  of  one  of  the  joints. 

The  circulation  is  probably  too  active  in  this  situation  to  allow 
of  deposition,  and,  thus,  marrow  takes  its  place  with  other  tissues 
and  organs  which  are  for  the  most  part  exempt  from  deposit,  with 
the  exception  just  mentioned. 

It  is  noteworthy  that  the  bones  of  the  gouty  manifest,  when 
dried,  a  more  fatty  appearance  than  bones  taken  from  the  sub- 
jects of  rheumatic,  strumous,  or  other  diathetic  disease.  There 
is  nothing  specially  to  be  remarked  in  respect  of  this  greasy 
appearance  in  recent  bones  from  gouty  subjects.  Sometimes  they 
appear  oily,  and  there  is  possibly  a  greater  amount  of  fat  in  the 
medullary  portion  than  is  normally  the  case.  Analyses  of  gouty 
bones  by  Marchand,  Lehmann,  and  Bramson  have  shown  diminu- 
tion of  earthy  salts  and  increase  of  fat.  M.  Budin 2  (quoted  by  Rendu) 
found  rarefaction  of  spongy  tissue  and  islets  of  ostitis,  granulo- 
fatty   transformation   of  osteo-blasts    (marrow-cells)    and    dilated 

1  In  a  case  reported  by  Fereol  (Union  Mid.,  p.  827,  1869)  deposit  was  found  in 
spongy  tissue  of  a  phalanx  unconnected  with  the  joint.  (Quoted  by  M.  Rendu, 
op.  cit.) 

2  Bull,  de  la  Soc.  Anat.,  1875,  P-  712- 


NODI    DIGITORUM    (HEBERDEN's)    SOMETIMES    GOUTY.       7  I 

vessels,  surrounded  with  crystals  of  margarine.  These  changes 
are  probably  largely  dependent  on  a  chronic  gouty  cachexia,  and 
are  hardly  to  be  expected  in  recent  or  less  grave  cases.  The 
bony  changes  occur  late,  and  subsequently  to  involvement  of  car- 
tilage and  less  yielding  structures,  and  are,  therefore,  so  far 
evidences  of  chronicity.  An  exception  must  be  made  to  this 
statement  in  respect  of  the  primary  affection  of  bone  which 
occurs  in  deforming  gouty  arthritis,  when  nodes  such  as  those 
described  by  Heberden  1  and  Haygarth  2  are  produced.  These  con- 
sist in  overgrowth  of  the  natural  tubercles  of  the  distal  digital 
phalangeal  bones.      I  am  convinced  that  amongst  cases  referred 

1  Nodi  digitorum. — This  term  was  applied  to  the  knotty  or  knobby  state  of  the 
terminal  phalangeal  joints  by  Heberden.  It  is  commonly  taught  that  these  are  not 
of  gouty  origin,  and  Heberden  denied  that  they  were  so.  "Nihil  certe  illis  commune 
est  cum  arthritide  ;  quoniam  in  multis  reperiuntur,  quibus  morbus  ille  est  incog- 
nitus."  *  Heredity  is  strongly  marked  in  respect  of  these  nodes.  An  eminent  mem- 
ber of  the  profession  thus  relates  his  own  case  to  me.  "  I  am  up  to  a  certain  point, 
though  in  a  very  minor  degree,  a  living  specimen  of  'digitorum  nodi,'  of  which, 
however,  I  am  aware  of  three  generations,  at  least,  of  ancestors  who  had  them  in  a 
much  more  confirmed  form,  and  associated  in  too  many  instances,  as  they  are  in  the 
case  of  two  of  my  brothers  and  one  sister,  with  really  serious  contractions  in  the 
palmar  fascia.  But  no  one  of  us  all,  so  far  as  I  know,  ever  had  a  fit  of  the  gout, 
and  this  holds  true,  I  believe,  of  all  the  three  generations.  Rheumatism,  more  or  less 
defined,  appears  in  one  of  my  brothers,  and  glycosuria  in  another  ;  t  but  none  of  us 
has  ever  had  rheumatic  fever,  and  this  also  applies  to  all  three  generations,  as  also 
the  immunity,  I  believe,  from  valvular  heart-disease.  It  is  very  interesting  that  in 
a  collateral  branch  of  our  cousinhood,  descended  from  our  great-grandfather,  gout 
appears  in  close  association  with  the  digitorum  nodi  and  the  palmar  contraction  ; 
but  then  the  father  of  these  was  gouty  and  probably  earned  it,  our  connection  with 
them  being  through  the  mother,  who  probably  brought  in  the  digital  deformities.  I 
may  add  that  the  nodes  run  mostly,  with  us,  in  the  female  line,  and,  so  far  as  I  know, 
they  have  come  on  without  any  kind  of  painful  symptoms,  and  usually  only  after  the 
middle  term  of  life." 

These  nodes  are  met  with  in  persons  in  very  advanced  life.  Charcot  has  noted 
that  in  women  thus  affected,  cancer  of  the  mamma  and  uterus  is  not  an  infrequent 
event,  and  my  own  experience  is  somewhat  confirmatory  of  this.  When  occur- 
ring in  men,  without  any  pronounced  gouty  or  rheumatic  concomitants,  they  may 
support  a  general  prognosis  for  longevity.  In  women  they  often  coexist  with 
hemicrania,  asthma,  severe  headaches,  and  other  troubles,  which  are  properly 
recognized  as  gouty  manifestations  of  the  sex.  They  may  precede  by  many  years 
overt  gouty  attacks.  Dr.  James  Begbie,  of  Edinburgh,  who  had  large  consulting 
practice  amongst  the  upper  ranks  in  Scotland,  was  convinced  of  the  occasional 
gouty  nature  of  Heberden's  nodes, J  and  recorded  several  cases  in  proof  of  this. 
He  noted  that  they  were  seldom  or  never  seen  on  the  fingers  of  the  industrious 
labourer  or  hard-working  mechanic,  but  found  chiefly  among  the  upper  classes  or  the 
luxurious  and  well-fed  of  their  dependents. 

2  Clin.  Hist,  of  Diseases,  Part  I.,  Acute  Rheumatism  and  Nodosity  of  the  Joints, 
1805. 

*  Commentarii,  cap.  xxviii.,  1802. 

t  This  brother  has  since  had  a  severe  attack  of  gout  in  left  great  toe-joint. 

J  Contributions  to  Practical  Medicine,  Edinburgh,  1862,  p.  27. 


72 


MORBID    ANATOMY    OF    GOUT. 


to  the  latter  categories  are  some  of  unquestionable  gouty  nature. 
These  may  arise  from  the  second  to  the  fifth  decade,  are  most 
common,  perhaps,  as  a  gouty  manifestation  in  women  about  or 
after  the  menopause,  but  are  not  uncommon  in  men  and  even  in 
children.     A  well-marked  instance  is  depicted  in  Fig.  5 ,  where  the 

diagnosis  of  rheumatoid  arthri- 
tis was  made  during  life  by  my 
colleague,  Dr.  Gee,  who  kindly 
permits  me  to  record  the  case. 
Unequivocally  gouty  changes 
were  found  after  death  with 
small  scattered  uratic  deposits.1 
True  synostosis  occurred  in 
several  of  the  phalangeal  joints. 
This  is  shown  at  A  in  Fig.  6, 
where  the  joint  has  been  ver- 
tically bisected.  No  line  of 
junction  is  seen  nor  any  remains 
of  the  compact  layers  of  bone. 
Garrod 2  records  a  case  of 
synostosis  of  first  joint  of  great- 
toe  after  a  few  attacks  of  gout. 
Scudamore  3  relates  the  details 
of  a  dissection  by  Brodie  of  a 
gouty  old  woman,  in  whom 
several  joints  of  the  fingers, 
as  well  as  the  right  wrist  and 
elbow,  and  several  toe-joints, 
were  ankylosed.  "  Chalky 
matter "  was  found  on  the 
bones  where  the  cartilage  had 
disappeared,  and  "  exostoses"  (lipping)  were  present  at  the  edges 
of  the  knee-joint. 

1  Heberden's  Nodes  in  a  Case  of  Gout — Jaundice — Death  from  Cancer  of  the 
Liver. — E.  G.,  nurse,  aged  63.  No  history  of  rheumatism,  or  of  gout,  known  of  in  the 
family.  Never  had  rheumatic  fever.  Began  to  have  what  she  called  "  gout"  in  the 
joints  of  the  fingers  ten  years  ago.  Attacks  first  came  in  the  interphalangeal  joints 
of  the  thumbs.  Has  had  it  many  times  since,  and  it  has  affected  from  time  to  time 
all  the  joints  of  the  fingers.  Since  the  attacks  began,  patient  has  noticed  a  gradual 
increase  in  size  of  the  joints  of  the  fingers.  Soon  after  the  attacks  of  "gout"  began 
in  the  fingers,  she  had  similar  attacks  in  the  metatarso-phalangeal  joints  of  the 
great-toes,  and  since  then  in  the  ankles  and  knees.  No  enlargement  of  these  joints 
was  noticed  by  the  patient.  No  tophi.  Heberden's  nodes,  both  hands.  Bones  of 
metatarso-phalangeal  joints  of  both  great-toes  slightly  flanged  (lipped).  Nothing 
noticeable  found  in  the  other  joints.  (The  hand  is  preserved  in  the  Hospital 
Museum.)  -  Op.  cit.,  p.  194.  3  Op.  cit.,  p.  48. 


Fig.  5. — Left  Hand  of  E.  G.  Drawn  from  a  plaster 
cast  taken  during  life.  Illustrating  nodi  digi- 
torum  of  truly  gouty  nature. 


KNOTTY    FIN GEll- JOINTS.       GOUTY    SYNOSTOSIS.  73 

In  some  examples  of  interstitial  nephritis,  so-called  cases  of 
primary  renal  gout,  such  nodular  arthritis  is  met  with  unasso- 
ciated  clinically  with  uratic  deposit  (vide  p.  99).  The  enlarge- 
ment consists  in  overgrowth  of  the  natural  tubercles  of  the 
phalanges,  which  become,  with  the  heads  of  the  bone,  somewhat 
expanded.  The  process  is  often  gradual  and  almost  painless, 
though  there  may  be  occasional  uneasiness  and  burning  sensa- 
tions in  these  joints. 

It  is  probable  that  Heberden  denied  the  appellation  of  gout 
to  those  nodules  because  they  occurred  without  the  ordinary 
classical  manifestations  of  gouty  arthritis,  and  were  met  with 
in  persons  who  presented  none  of  the  recognized  and  overt  signs 


Fig.  6.— Right  Hand  of  E.  G. 
(A.)  Illustrating  true  gouty  synostosis  ;  (£.)  Nodi  digitorum. 

of  what,  in  his  time,  was  alone  regarded  as  true  gout.  It  is  cer- 
tain that  nodes  undistinguishable  from  these  occur  in  persons 
who  are  not  gouty.  Their  gouty  nature,  in  any  given  case,  is 
determined  by  other  concomitants,  which  may  be  discovered  by 
those  who  know  what  to  look  for.  These  nodular  enlargements 
are  often  red,  and  prone  to  become  hot  and  painful  from  various 
causes.  Fugitive  achings  may  occur  in  them  after  dietetic  errors. 
Chronic  irritation  of  articular  cartilage  leads  in  any  case  of 
arthritis,  however  induced,  to  the  formation  of  exostoses  or 
ecchondroses  —  so-called  "lipping" — which  arise  beneath  the 
synovial  membrane  at    the   edges  of   the   cartilages,   and  round 


74 


MORBID  ANATOMY  OF  GOUT. 


the  heads  of  the  phalanges  or  other  bones,  as  in  the  femora, 
patellae,  or  tibiee.  In  gouty  arthritis  these  are  less  exaggerated 
than  in  truly  rheumatic  disease,  and,  as  already  noted,   seldom 


Fig.  7. — Section  of  Margin  of  Healthy  Adult  Knee  (Femur),  for  comparison  with 
Figs.  8,  9,  10,  and  11. 

lead  to  stalactitic  (osseous)  proliferation.  In  opening  joints  thus 
affected,  everted  edges  of  irritative  exostosis  are  witnessed,  often 
more  translucent  than  the  naturally  investing  cartilage,  and  with 
sinuous  margins.     Commonly,  there  is  associated  deposit  of  urates, 


"'--■•' 7 


Fig.  8. — Section  at  Edge  of  Femur  showing  Gouty  Exostosis  or  "Lipping." 

(a.)  Osteophyte  of  ill-formed  cancellous  bone  ;  (6.)  Reflection  of  synovial  membrane  (s)  ;  (c.)  Limit 

of  cartilage  cells  ;  (d.)  Articular  cartilage  of  lemur ;  (/.)  Cancellous  tissue  ;  (p.)  Periosteum. 

more  or  less,  but  not  always,  and  this  is  rarely  seen  over  the 
exostosis,  but  more  often  towards  the  centre  of  the  cartilages. 
It  may,  however,  occur  in  proliferating  cartilage,  occupying  the 
primary  capsules,  which  include  numerous  secondary  ones. 


HISTOLOGY    OF    GOUTY    KXOSTOS1 


75 


As  pointed  out  by  Cornil  and  Ranvier,  this  formation  of  mar- 
ginal outgrowths  is  inevitable  in  any  form  of  chronic  arthritis. 
There  is  less  in  the  scrofulous  than  in  the  gouty  form,  and  most 
in  the  rheumatic  variety.  Proliferation  occurs  at  the  borders  of 
the  articular  cartilage,  and  atrophy  at  the  centre.  Cornil  and 
Ranvier  affirm  that  the  former  process  is  caused  by  the  fibro- 
synovial  investment  of  the  edges,  already  described,  whereby  the 
proliferating  elements  of  the  cartilage,  fibrous  villi  and  cells,  are 
shut  in,  and  must,  perforce,  accumulate,   instead  of  being  cast  off 


,  Illli 


\-t-d 


9-cL 


X 


Fiq.  9. — Section  of  Gouty  Exostosis. 
(a.)  Synovial  fringe  ;  (&.)  Prolongation  of  same  over  outgrowth  ;  (c.)  First  appearance  of 
cartilage-cells  ;  (d.)  Vessels  of  periosteum. 

into  the  cavity  of  the  joint,  as  occurs  in  the  central  or  non-syno- 
vially  invested  portions.  In  this  manner  nodules  are  produced 
in  articular  cartilage,  on  synovial  fringes,  and  on  tendons  and  liga- 
ments, fibrous  synovial  investment  at  these  points  surrounding 
the  irritative  overgrowth. 

Dr.  Wynne  has  made  a  careful  study  of  the  intimate  structure 
of  these  marginal  outgrowths,  both  in  gouty  and  chronic  rheu- 
matic arthritis,  and  I  am  indebted  to  him  for  the  details  and 
illustrations  which  follow.1      (Vide  Figs.  7—1  1.) 

1   Vide  Note  on  a  Point  of  Difference  in  the  Pathology  of  Gouty  and  Rheumatoid 
Arthritis,  by  E.  T.  Wynne,  M.B.,  Cantab.     Lancet,  May  II,  1889,  p.  933. 


76 


MORBID    ANATOMY    OF   GOUT. 


Marginal  outgrowths  in  gouty  arthritis  are  true  exostoses.— 
The  peculiar  enlargement  has  much  coarse  resemblance  to  that 
met  with  in  cases  of  chronic  rheumatic  arthritis.  It  is  not 
directly  connected  with  uratic  deposition,  and  the  enlarged  por- 
tions are  commonly  void  of  such  deposit.  It  is  apparently  due 
to  an  overgrowth  of  cartilage ;  but  this  tissue  does  not  ex- 
tend to  the  summit  of  the  outgrowth,  and  is  replaced  by  a 
yellow,  translucent  texture,  which  offers  great  resistance  to  the 
knife.   Examined  microscopically  {vide  Figs.  8,  Q,  10),  this  latter 


Fig.  10. — Section  of  Gouty  Exostosis  (made  at  x  in  Pig.  9).  Illustrating  absence  of  encrusting 
cartilage,  the  bony  outgrowth,  being  invested  by  fibrous  tissue  prolonged  from  the  synovial 
membrane. 


substance  is  found  to  be  composed  of  bony  matter,  the  epiphysis 
appearing  to  be  locally  hypertrophied,  and  pushing  the  encrusting 
cartilage  before  it.  The  latter  is  seen  to  terminate  abruptly  at 
the  summit  of  the  protuberance,  when  it  becomes  continuous 
with  a  thin  layer  of  fibrous  tissue  derived  from  the  periosteum 
and  synovial  membrane.  Beneath  this  fibrous  tissue  is  found 
spongy  bone,  identical,  and  continuous,  with  the  cancellous  tex- 
ture of  the  subjacent  bone.  These  appearances  are  constant  in 
true  gouty  arthritis. 

Marginal  outgrowths  or  "lipping"  round  joints  affected  with 


HISTOLOGY   OF    RHEUMATIC    ECCHONDROSIS. 


77 


chronic  rheumatic  arthritis  are  due  to  ecchondrosis. — In  chronic 
rheumatic  arthritis  there  are  found  ridged  or  lipping  outgrowths  due 
to  overgrowth  of  cartilage,  usually  fibrillated,  which  may  in  their 
deeper  parts  be  calcified,  but  rarely  show  true  bone-structure.  In 
the  case  of  gouty  arthritis,  therefore,  this  "  lipping  "  outgrowth  is  a 
true  exostosis,  while  in  the  rheumatic  variety  of  this  enlargement 
the  change  is  a  true  ecchondrosis.  (Vide  Fig.  I  I.)  Dr.  Wynne 
suggests  that,  in  the  latter,  the 
change  is  probably  due  to  a 
nervous  dystrophy,  while  in 
the  gouty  form  the  overgrowths 
result  from  the  irritative  action 
of  uratic  deposit  in  the  vicinity, 
or  from  the  abnormal  presence 
of  urates  in  the  blood  circulat- 
ing through  the  bone.  These 
results  constitute  a  new  con- 
tribution to  the  intimate  mor- 
bid anatomy  of  gout  and  of  chro- 
nic rheumatic  arthritis,  which 
reflects  great  credit  on  the 
painstaking  observations  of  Dr. 
Wynne.  In  particular,  they 
contradict  the  teaching  of  MM. 
Oornil  and  Ranvier,  which  has 
up  to  this  time  been  generally 
accepted.  These  observers  re- 
gard the  changes  in  question 
as  due,  in  each  case,  to  true 
ecchondroses.  They  must  hence- 
forth be  differentiated. 

Erosion  of  the  cartilage  may 

d,  -i  p  Fig.  ii. — Section  of  Ossifying  Rheumatic  Ecchon- 

atiropny    irom    COn-  drosis  (Lipping),  showing  complete  investment 

tinued  motion  in  a  joint  admit-  by  cartilage' which  is  uader»oi^  fibrillation, 
ting  free  play.  It  is  rare  to  meet  with  it  in  those,  such  as  the 
carpal  or  tarsal  joints,  which  move  but  slightly.  This  happens, 
perforce,  in  gouty  and  rheumatic  arthritis,  but  greater  ravages 
occur  in  the  latter.  In  joints  thus  affected,  pain  on  motion  is  felt 
during  life,  and  crackling  is  also  audible.  Pain  is  not  always 
present,  unless  there  is  active  gouty  inflammatory  process  at  work. 
The  knee  is  perhaps  most  frequently  thus  affected. 

Eburnation  appears  to  be  extremely  rare  as  a  result  of  gout 
in  a  joint,  and,  indeed,  the  measure  of  bony  changes  anywhere 


i  ofot 

TO, 


78  MORBID    ANATOMY    OF    GOUT. 

in  true  gout  seems  to  be  in  relation  both  to  the  severity  and 
chronicity  of  the  attacks  in  the  part. 

It  is  noteworthy  that  true  bony  ankylosis  (synostosis)  is  met 
with  as  an  occasional  result  of  gouty  arthritis,  while  it  is  almost, 
if  not  quite,  unknown  as  a  sequel  of  chronic  rheumatic  arthritis. 
In  the  latter,  false  ankylosis  is  common  enough  from  proliferative 
periarthritic  growths,  or  from  fibrous  or  fibro-cartilaginous  change. 
The  former  I  have  met  with  in  the  great-toe  1  and  in  the  phal- 
angeal joints  (vide  Fig.  6).  The  cavity  of  the  joint  may  be  re- 
placed by  new  spongy  bone  in  which  a  white  line  (seen  on  section) 
indicates  sometimes  the  original  articular  surfaces. 

The  joint  may  be  filled  with  urates  separating  the  two  bones. 

It  is  worthy  of  note,  in  respect  of  the  varied  deformities  occur- 
ring in  the  phalanges  of  the  hand,  that  their  innervation  is  derived 
from  the  median  nerve.  My  colleague,  Mr.  Walsham,  has  demon- 
strated that  the  radial  and  ulnar  nerves  do  not  go  beyond  the 
end  of  the  first  phalanx.  The  terminal  extremities  are  animated 
by  branches  of  the  median  nerve  which  pass  onwards  from  the 
metacarpal  muscles. 

Ostitis  induced  by  proximity  of  infiltrating  deposit  may  be 
either  of  the  condensing  or  rarefying  varieties. 

The  ends  of  the  bones  are  often  enlarged.  There  may  be 
much  thickening  in  long  bones,  as  in  one  instance,  recorded  by 
my  colleague,  Dr.  Moore,2  who  found  new  bone  (osteoma)  in  the 
lower  half  of  a  tibia,  exceeding  the  diameter  of  the  normal  bone, 
without  change  either  in  the  medullary  cavity  or  periosteum,  and 
without  signs  of  old  fracture  at  the  part. 

Urates  are  sometimes  present  in  the  fat  outside  of  joints, 
perhaps  most  often  about  the  knees. 

Synovia. — The  synovia  often  contains  specks  of  urates,  and 
may  be  unduly  vascular.  I  have  met  with  spicules  of  urates  on 
synovial  fringes.  This  is  rare.  I  have  found  the  synovia  alka- 
line in  a  gouty  knee-joint,  with  granular  flocculi  and  acicular 
sodium  urate  crystals  in  it.  With  the  thread-test  I  got  negative 
results  in  the  clear  fluid.  It  contained  no  glucose.  In  another 
case,  where  the  synovia  was  very  abundant  in  an  encrusted  knee- 
joint,  I  found  the  reaction  slightly  acid.  The  fringes  may 
become  much  hypertrophied  and  infiltrated  with  fat  (dendritic 
lipoma).       Deposits   may  be   found  in   every   component   tissue 

1  Mr.  Shattock  has  reported  an  example  of  true  gouty  synostosis  of  the  great-toe 
(Path.  Soc.  Trans.,  p.  280,  vol.  xxxix.  1888.)  He  kindly  showed  me  this  specimen. 
Uratic  deposits  were  found  around  the  joint. 

2  Path.  Soc.  Trans.,  vol.  xxxiii.,  p.  275,  1882. 


AXIAL    DISTORTION    OF    DIGITS.  /9 

of  a  joint,  and  are  met  with  in  connective  tissue,  intermus- 
cular connective  tissue,  in  nerve-sheaths,  periosteum,  preverte- 
bral fascia,  tendons  and  their  sheaths,  ligaments,  and  in  fibro- 
cartilage. 

Axial  distortion  of  digits  ("seal-fin"  type  of  hands).— A  note- 
worthy point  frequently  to  be  observed  in  gouty  arthritis,  as  in 
most  other  forms  of  chronic  arthritis,  is  the  peculiar  deflection 
of  the  digits  to  the  ulnar  side  of  the  fore-arm.  The  toes  some- 
times assume  a  distortion  to  the  outer  side  of  the  foot.  It  has 
been  taught  that  this  is  a  specific  indication  of  chronic  rheu- 
matic arthritis,  but  this  is  certainly  not  true.  I  think  the  deflec- 
tion is  more  often  found  in  rheumatic  than  in  gouty  cases,  but 
I  have  met  with  it  equally  well-marked  in  both.  Chronicity  is 
certainly  signified  by  it. 

The  cause  of  this  axial  distortion  is  to  be  found  in  the  influence 
of  the  extensor  muscles  of  the  wrist  and  fingers.  The  move- 
ments of  adduction  at  the  wrist  are  more  free  than  those  of 
abduction,  and,  therefore,  the  muscles  when  unchecked  tend  to 
draw  the  fingers  inwards.  I  believe,  with  Charcot  and  others, 
that  there  is  a  reflex  action  on  the  musculo-motor  nerves  excited 
by  irritation  of  the  sensory  branches  in  the  affected  joints  leading 
to  spasmodic  contraction,  which  in  course  of  time  induces  the 
characteristic  distortion  of  the  digits  referred  to.1 

In  the  case  of  the  deflected  or  abducted  toes,  it  has  been 
sought  to  prove  that  these  result  entirely  from  badly-shaped 
boots.  Mr.  Arbuthnot  Lane,  in  particular,  is  dogmatic  on  this 
point.2  I  cannot  agree  with  this  view.  It  is  certain  that  most 
feet  are  distorted  and  compressed  to  some  degree  by  wearing 
boots,  but  the  cases  in  which  abduction  is  considerable  are  almost 

1  Dr.  Herringham  seeks  to  explain  the  ulnar  deflection  of  digits  as  a  result  of 
atrophy  of  the  abductor  indicis  muscle,  which  leads  to  this  displacement  of  the  index 
finger,  itself  pressing,  in  turn,  on  the  other  digits.  Against  this  view  must  be  placed 
the  fact  that  such  atrophy  is  most  inconstant,  and,  therefore,  not  present  in  all  cases. 

Direct  experiments  have  been  made  to  determine  the  influence  of  muscular  con- 
traction in  inducing  deformities  of  joints.  M.  Valtat  made  caustic  injections  into 
the  joints  of  dogs  and  guinea-pigs,  and  found  afterwards  contractures  of  muscles 
bordering  on  these  articulations.  He  witnessed  contractures  first  induced  by  arthritis, 
and  subsequent  atrophy  of  the  muscles,  and  attributed  this  to  over-excitement  of 
reflex  activity  of  the  spinal  chord  from  prolonged  peripheral  stimulus.  As  analogous 
instances,  he  mentions  articular  spasm  caused  by  irritation  of  the  conjunctiva,  and 
anal  fissure  maintained  by  spasm  of  the  sphincters.  He  regards  contracture  as  the 
analogue  of  hypersesthesia,  occurring  when  the  motor  portion  of  the  chord  is  stimu- 
lated (Lecture  by  M.  Charles  Richet,  Lancet,  May  21,  1881,  p.  816). 

2  Path.  Soc.  Trans.,  vol.  xxxvii.,  p.  433,  1886.  Mr.  Lane  attributes  the  "so- 
called  "  disease — chronic  rheumatic  arthritis — entirely  to  the  results  of  transmission 
of  pressure. 


8o 


MORBID    ANATOMY    OF    GOUT. 


always,  in  nay  experience,  the  subjects  of  rheumatic  or  gouty 
habit.  The  distortions  are  very  frequent  in  women,  even  in 
ladies,  who  seldom  wear  such  strong  boots  as  alone  could  compass 
the  extreme  changes  referred  to.  If  boots  alone  were  to  blame, 
such  distorted  feet  should  be  much  more  common  than  they 
are.  In  extreme  cases  the  great-toe  is  everted  almost  at  a  right 
angle,  and  overlaps  all  the  other  toes.     Cases  of  unequivocal  gout 


Yia.  12. Tophaceous  Gout  of  Right  Hand.    Deflection  of  digits  to  ulnar  aspect.    On  the  wrist  a 

scar  of  a  large  "chalky"  deposit  which  had  been  treated  by  incision. 

are  often  seen  where,  with  involvement  of  small  joints,  the  digits 
are  quite  straight  in  their  axial  lines,  and  it  is  commoner  to  see 
merely  displacements  of  the  phalanges  in  one  or  two  fingers. 
Thus,  the  terminal  bones  may  be  bent  in  or  out,  and  a  frequent 
change  is  a  deflection  outwards  of  the  last  phalanx  of  the  fore- 
finger, and  one  inwards  of  that  of  the  little  finger  in  the  same 
case.  I  have  observed  this  with  some  frequency  in  chronic  gouty 
hands  of  women.1      (Vide  Figs.  13,  14.) 

1  "  Adduction  is  effected  to  a  greater  extent  than  abduction  in  consequence  of  the 
mode  of  disposition  of  the  lateral  ligaments,  and  with  greater  power  in  consequence 


DISTORTIONS    OF   PHALANGES.  8 1 

Flexion  into  the  palm  of  the  first  phalanx  of  the  middle 
finger,  and  of  the  distal  phalanx  of  the  same  digit,  is  somewhat 
common  in  men,  and  the  bones  of  the  ring-finger  may  be  simi- 
larly involved.  These  changes  are  seen  with  and  without  much 
uratic  deposit  (Fig.  15). 

One  of  the  most  commonly  affected  joints  is  the  metacarpo- 
phalangeal of  the  forefinger.  It  is  rare  to  find  deposits  elsewhere, 
if  this  joint  be  free.1  All  the  types  of  deflection  described  by 
Charcot  as  met  with  in  chronic  rheumatic  arthritis,  or  combina- 


Fig.  13. — Gouty  Heberden  s  Nodes.  Illustrating 
common  forms  of  terminal  phalangeal  deflec- 
tion. Forefinger  and  little  finger  of  a  woman, 
set.  70.  "  Crab's-eye"  cysts  over  the  joints 
are  also  depicted. 


Fig.  14. — Illustrating  Nodular  Swellings 
(Heberden's  Nodes)  due  to  gouty 
arthritis  on  the  fore-finger  and  little 
finger  of  a  lady,  set.  50. 


tions  of  them,  may  be  found  in  the  gouty ;  and  the  same  law, 
doubtless,  explains  them  in  both  diseases. 

Haemorrhage  may  occur  into  the  joints.  Dr.  Pye-Smith  has 
recorded  an  instance  where  this  was  met  with  in  the  knees,  hips, 
great-toes,  ankles,  wrists,  and  one  elbow.  The  shoulders  were 
free  from  bloody  effusion.      The  blood  was  dark  and  recent,  but 

of  the  leverage  afforded  by  projection  of  the  cuneiform  and  pisiform  bones  on  the 
inner  side  of  the  wrist.  Thus,  the  hand  assumes  the  position  of  adduction  and  the 
little  finger  becomes  inclined  to  the  ulna  when,  from  disease  or  other  cause,  the 
muscles  lose  the  influence  of  volition,  and  exercise  an  uncontrolled  sway  over  the 
part." — A  Treatise  on,  the  Human  Skeleton,  p.  427.  Prof.  Humphry,  Cambridge, 
1858. 

1  In  one  case  with  deposits  in  great-toes,  right  knee  (only  one  opened),  and  left 
ear,  this  joint  was  free  from  deposit,  ibut  the  cartilage  was  much  eroded.  This 
occurred  in  a  man,  set.  circ.  forty-five,  who  died  from  cerebral  haemorrhage,  and  had 
granular  kidneys. 

F 


82 


MOEBID  ANATOMY  OF  GOUT. 


in  one  hip  was  rusty  and  brown.  In  some  joints  the  synovial 
membrane  was  infiltrated  with  blood.  In  this  case  the  choroid 
plexus  was  deeply  discoloured,  owing  to  infiltration  of  the  pia 
mater  with  large  altered  blood-discs,  which  had  not,  however,  dis- 
integrated.1 Such  an  example  recalls  somewhat  the  appearances 
met  with  in  the  joints  in  some  cases  of  heemophilia.2 

The  synovial  membrane  is  sometimes  greatly  congested,  and 
thrown  into  folds,  which  project  into  the  joints.  Fagge  recorded 
a  notable  example  in  which  loose  flakes  of  lymph,  much  synovial 
fluid,  and,  in  one  joint,  thin  watery  pus  were  also  found,  the 
latter  burrowing  into  the  adjacent  thenar  muscles  of  the  thumb. 


Fig.  15. — Tophaceous  Gout  of  Hands,  illustrating  deflection  and  torsion  of  digits  and 
phalanges,— "  seal-fin  "  type. 

Dr.    Goodhart  found    very   similar   conditions  in  another    case.3 
These  appearances  are  very  uncommon. 

Suppurative  Arthritis  in  Gout. — Pus  is  rarely  found.  Amongst 
the  cardinal  distinctions  of  gouty  arthritis  are  its  aseptic  course 
and  the  absence  of  suppurative  tendency.  In  bursal  sacs  impreg- 
nated with  urates,  inflammatory  changes  going  on  to  forma- 
tion of  pus  may  be  occasionally  met  with.  The  bursa  over  the 
olecranon  is  the  most  frequent  site  for  this,  and  here  it  may  per- 
haps be  induced  by  injuries.      Scudamore4  met  with  four  cases 

1  Path.  Soc.  Trans.,  vol.  xxvi.  p.  162,  1875. 

2  Dr.  Barlow  has  related  to  me  the  case  of  a  voimg  man  who  had  heemophilia,  with 
epistaxis,  hematuria,  and  effusions  into  the  joints,  and,  subsequently,  uratic  tophi  in 
the  ears. 

3  Path.  Soc.  Trans.,  vol.  xxvi.  p.  164.  4  Op.  cit.,  p.  146. 


GANGRENE.    BURSAL  CYSTS.    DUPUYTREN'S  CONTRACTION.      83 

of  suppuration  as  the  termination  of  gouty  inflammation,  the 
result  being  modified  in  each  case  by  an  attendant  secretion  of 
urates.  Norman  Moore  1  found  puriform  fluid  in  a  gouty  knee- 
joint  in  a  man  set.  forty-six.  Mr.  Stephen  Paget  has  related  a 
case  of  purulent  gonarthritis  in  a  man  set.  forty-nine,  long  gouty, 
and  quotes  another  example,  recorded  by  Mr.  Ilivington,  of  sup- 
puration involving  the  wrist-joint  in  a  man  aet.  sixty-two.2  Mr. 
Hutchinson  has  met  with  suppuration  in  the  great  toe-joint, 
with  uratic  deposit.  Sometimes  a  circum-articular  abscess  breaks 
into  a  joint,  septical  matters  being  thus  introduced  from  without. 

Gangrene. — Gouty  inflammation  has  been  known  to  pass  into 
gangrene,  with  sloughing  of  the  integuments  about  the  great- 
toe,  and  without  associated  glycosuria.  Gangrene  is  not  infre- 
quent as  a  result  of  acute  gout,  or  of  injury  to  peripheral  parts 
in  the  subjects  of  chronic  gouty  glycosuria.  Gangrenous  gouty 
inflammation  may  result  from  enfeebled  powers  in  the  aged,  and 
in  gouty  cachectic  subjects.  Dr.  Quain  has  related  to  me  an 
instance  of  this  kind  which  proved  fatal  in  an  elderly  gouty 
subject. 

Bursal  Cysts Over  the  nodules,  and  also  just  above  the  nail, 

at  the  last  phalangeal  joints,  may  sometimes  be  found  small  cystic 
swellings  of  the  integument.  These  have  been  likened  rather  aptly 
to  crabs'  eyes.  I  have  hitherto  only  met  with  them  in  women 
in  middle  or  advanced  life.  Paget  and  Garrod  have  described 
these.  I  believe  they  are  due  to  small  and,  perhaps,  adventi- 
tious synovial  bursas.  Sometimes  they  burst,  and  there  issues 
from  them  a  clear,  viscid  fluid,  in  which  I  have  not  detected 
uratic  salts.  When  they  are  tumid  there  is  some  pain  and  heat 
in  them,  and  pressure  yields  a  delicate  crunching  sensation  to 
the  finger,  such  as  is  found  in  ordinary  inflamed  bursas.  I  have 
never  observed  these  in  any  but  Heberden's  nodes  of  gouty  origin, 
and  only  rarely  in  these.  Their  appearance  is  depicted  in  Fig. 
13.  In  time  the  contents  become  dry,  and  the  nodule  hardens. 
They  may  subside  for  months,  and  reform  as  before. 

Dupuytren's  Contraction. — Contraction  of  the  palmar  fascia, 
known  as  Dupuytren's  contraction,  is  more  apt  to  occur  in  gouty 
than  in  other  persons.  If  pressure  alone  were  the  cause  of  this, 
we  should  more  frequently  meet  with  it.  Pressure  is  the  exciting 
cause,  but  is  mainly  potential  in  the  gouty  or  arthritic  habit  of 
body.3     It  is  not  usual  to  find  other  overt  gouty  changes  in  these 

1  Path.  Soc.  Trans.,  vol.  xxxiii.  p.  274. 

2  Clin.  Soc.  Trans.,  vol.  xx.  1887,  p.  232. 

3  Vide  De  la  retraction  spontanie  et  progressive  des  doigts  dans  ses  rapports  avec  la 
goutte  et  le  rhumatisme  goutteux.     Par  A.  L.  Menjaud,  These,  Paris,  1861. 


U 


MORBID    ANATOMY    OF    GOUT. 


subjects,  and  hence  it  is  to  be  regarded  as  one  of  the  manifesta- 
tions of  incomplete  gout.  It  is  often  hereditary.  The  plantar 
fascia  is  less  often  affected  in  this  manner.  The  integuments 
become  adherent  to  the  fascia,  and  thus  puckered,  because  blended 
with  it  in  parts.  The  sheaths  of  the  flexor  tendons  are  also 
involved,  but  the  tendons  and  joints  are  not  implicated. 

Uratic  deposits  attain  at  times  enormous  size.  The  largest  are 
invariably  around  some  joint,  and  the  upper  extremities  furnish 
the  most  marked  examples.      (Vide  Fig.   16.)      Section  of  these 


Fig.  16. — Tophaceous  Gout.     Both  hands  were  symmetrically  affected      Man,  set.  60. 
Enormous  tophi. 


tumours  shows  that  many  of  the  changes  induced  are  due  to  long- 
continued  mechanical  pressure,  leading  to  absorption  of  much 
normal  texture.  As  these  deposits  approach  the  surface,  they 
tend  occasionally  to  burst  through  the  skin,  and  great  relief  to  all 
the  troubles  engendered  is  afforded  by  a  flow  of  pultaceous  creti- 
form  urates,  and  the  deformities  greatly  subside.  In  this  fashion 
many  ounces  of  urates  are  got  rid  of,  and  patients  sometimes 
bring  with  them  parcels  of  these  collections. 


BRONCHITIS    AND    PULMONARY    EMPHYSEMA. 


II.— Abarticular  and  Visceral  Gout. 

Deposits  in  internal  organs  are  of  extreme  rarity.  Cases  have 
been  described  which  were  supposed  to  illustrate  this  in  the  car- 
diac valves  and  inner  tunic  of  the  aorta,  in  the  bronchial  glands 
and  tubes,  and  the  meninges  of  the  brain.  Few  of  these  obser- 
vations have  been  made  since  the  chemical  reactions  of  uric  acid 
have  been  better  understood.  In  some  of  these  instances  only 
slight  traces  of  the  acid  were  found,  associated  with  lime  salts 
commonly  met  with  in  the  situations  mentioned.  Lancereaux, 
Bence  Jones,  Dr.  Sansom,  and  Dr.  Sydney  Coupland  have  found 
urates  in  concretions  of  the  mitral  and  aortic  cardiac  valves,  and 
so  has  Bramson  in  plates  from  the  arch  of  the  aorta. 

Respiratory  System. — Crystals  of  uric  acid  have  been  detected 
in  the  sputa  of  a  gouty  patient  by  Dr.  J.  W.  Moore  of  Dublin,1 
and  by  Lecorche.2  Garrod  met  with  encrustation  of  the  arytenoid 
cartilages  in  one  case.  This  must  be  very  rare.  Virchow  de- 
tected a  "  tophulus  "  in  the  posterior  part  of  the  right  vocal 
chord.3  Litten,  in  an  account  of  post-mortem  appearances  in  a 
very  gouty  man,  aged  forty-one,  describes  uratic  deposits  in  the 
crico-aryteenoid  ligaments,  which  extended  in  the  form  of  broad 
white  stripes  between  the  articulating  surfaces  of  both  the  car- 
tilages, and  nearly  filled  up  the  joints.4  Dr.  Norman  Moore  has 
reported  a  case  of  saturnine  gout  in  which  small  deposits  were 
found  in  both  vocal  chords,  none  being  found  in  the  crico-aryteenoid 
joints.5  In  this  case  there  was  deposit  in  the  pia  mater  over  the 
anterior  cerebral  lobe,  a  half  by  a  quarter  of  an  inch  in  extent, 
the  dura  mater  not  being  adherent  to  it. 

Patches  of  congestion  are  sometimes  found  on  the  vocal  chords 
during  life  with  symptoms  of  catarrh,  and  are  met  with  in  gouty 
persons  without  any  overt  exposure  to  ordinary  causes  of  catarrh. 

Bronchitis. — There  are  found  signs  of  irritation,  such  as  chronic 
congestion  of  the  bronchial  mucous  membrane,  in  cases  of  gouty 
cachexia.      Laryngitis  of  gouty  origin  is  rare,  but  not  unknown. 

Bronchitis  is  very  common  after  middle-life  in  gouty  persons. 
It  may  alternate  with  articular  gout,  or  with  some  skin-affection, 
as  psoriasis  or  eczema.  With  this  is  associated  hypertrophous 
emphysema,  resulting  mechanically  from  cough,  its  primary  cause 
being   degeneration   of   the    small  vessels  and  capillaries,  which 

1  Irish  Hosp.  Gazette,  July  15,  1873. 

2  Op.  cit.,  p.  319.  3  Archiv,  vol.  xliv. 

4  Virchow's  Archiv,  vol.  lxii.  p.  132,  1876.     (Dr.  Semon  has  kindly  given  me  this 
reference.)  6  p^  Soc.  Trans.,  vol.  xxxiii. 


86  MORBID  ANATOMY  OF  GOUT. 

become  obliterated  and  fatty,  together  with  the  epithelium  of  the 
alveoli,  thus  leading  to  atrophy  and  rupture  of  the  walls  of  the  latter. 

Emphysema. — According  to  Dr.  Norman  Moore,  emphysema  is 
as  constant  a  lesion  in  the  gouty  as  is  interstitial  nephritis. 
It  is  par  excellence  the  pulmonary  lesion  of  the  gouty.  With 
emphysema  is  associated  hypertrophy  of  the  right  ventricle  of  the 
heart,  which  is  long  compensatory  of  the  difficulties  of  the  cir- 
culation in  the  pulmonary  artery.  As  in  most  of  these  cases 
we  have  to  do  with  chronic  nephritis,  it  is  hardly  possible  to 
determine  in  each  how  much  of  the  existent  morbid  anatomy  is 
dependent  on  the  renal  mischief  alone.  The  occurrence  of  uric 
acid  in  the  sputa  of  a  gouty  bronchitic  patient  has  been  already 
alluded  to. 

Pneumonia  (Arthritic  Pneumonia). — Gout  is  known  to  cause 
pneumonia.  Some  authors  deny  this,  but  there  is  no  room  to 
doubt  the  fact.  The  cases  occur  in  persons  of  gouty  habit,  and 
are  not  always  preceded  by  arthritis.  Cold  is,  perhaps,  the  com-' 
monest  exciting  cause.  The  pneumonia  is  lobular,  but  may  be 
patchy  and  "  ambulans,"  affecting  both  lungs.  It  does  not  form 
part  of  the  arthritic  attack  after  the  manner  of  a  rheumatic  pneu- 
monia. The  physical  signs  are  such  as  are  usually  present,  and 
the  sputa  are  often  rusty,  and  even  bloody  in  the  aged  and 
exhausted.  Several  attacks  may  occur  at  long  intervals,  be  re- 
covered from,  and  leave  the  lungs  unimpaired.  Herpes  labialis 
is  not  uncommon  in  these  cases.  The  pneumonic  symptoms  may 
be  rapidly  relieved  by  onset  of  articular  gout. 

Catarrhal  pneumonia  is  sometimes  met  with. 

Congestion  with  oedema  is  found  at  the  bases  of  the  lungs  in 
cases  of  cardiac  dilatation  and  failure. 

Embolic  Pneumonia. — Embolic  pneumonia  results  in  cases  of 
gouty  phlebitis.1  It  may  prove  fatal,  or  be  recovered  from.  The 
base  of  the  lung  is  most  commonly  involved.  The  sputa  are 
mucous  and  very  bloody,  like  currant  jelly.  Branches  of  the 
pulmonary  artery  may  be  plugged  first  in  one  and  then,  later,  in 
the  other  lung.  The  emboli  may  soften  and  become  puriform, 
and  may  thus  become  sources  of  general  septical  infection. 

This  form  of  pneumonia  may  also  be  patchy,  and  involve  both 
lungs. 

Pleurae. — Pleural  effusion  I  believe  to  be  infrequent  in  the 
earlier  stages  of  gout,  and  I  can  hardly  support  Fraentzel's  state- 
ment  that   attacks   of   pleurisy  are    common  in  gout.2      Garrod 

1   Vide  Cases  reported  by  Tuckwell,  St.  Barth.  Hosp.  Reports,  vol.  x.,  1874. 
2  Ziemssen's  Cyclopaedia,  vol.  iv.  p.  597. 


DIGESTIVE    SYSTEM.       TONGUE.  87 

mentions  the  occurrence  of  a  species  of  dry  pleurisy,  which  may 
also  attack  the  diaphragm,  causing  violent  spasmodic  cough. 
Charcot  considers  that  these  are  probably  cases  of  simple  pleuro- 
dynia. In  examining  the  bodies  of  those  who  have  died  from  gouty 
cachexia  with  degenerate  hearts  and  kidneys,  effusions  are  not 
infrequently  found  in  the  pleurae.  Garrod  found  uric  acid  in 
pleural  effusions.  Pleuritic  adhesions  are  somewhat  commonly 
met  with  in  autopsies  of  the  gouty.  Ebstein  records  the  case 
of  a  man,  aged  sixty-three,  the  subject  of  articular  gout,  who 
suffered  from  intense  bronchitis  with  emphysema.  After  a 
sharp  fit  in  a  foot  and  a  hand  lasting  five  days,  violent  pain 
came  on  in  the  left  pleura  with  a  moderately  large  effusion,  proving 
fatal  in  two  days.  At  the  autopsy  there  was  found  interstitial 
(uratic)  nephritis,  and  hypertrophy  of  the  bladder  and  prostate, 
the  latter  suppurating,  and  evidently  the  cause  of  pyaemia.  There 
were  haemorrhagic  pleural  effusion,  abscesses  in  the  left  lung,  and 
commencing  suppurative  pericarditis.  The  left  ventricle  of  the 
heart  was  hypertrophied.  Uratic  deposits  were  present  in  both 
great-toe- joints. 

Digestive  System— Tong-ue.— The  tongue  presents  no  noteworthy 
objective  features.  But  the  gouty  may  suffer  from  deep-seated 
pain  in  the  tongue,  which,  as  Paget  has  declared,  may  sometimes 
cause  apprehension  of  cancer.  This  neuralgia  seldom  lasts  more 
than  a  day  or  two,  and  is  more  often  met  with  in  cases  of  irre- 
gular and  incomplete  gout.  A  peculiar  sense  of  heat  and  burn- 
ing is  sometimes  experienced.1 

Psoriasis  of  the  tongue  is  apt  to  occur  in  the  gouty.  It  may 
vary  in  extent  from  a  small  patch  to  one  covering  the  greater 
part  of  the  organ.  In  colour  these  may  be  bluish,  and,  if  thin, 
are  shiny  and  glistening,  with  the  "snail-track"  character. 
Thicker  patches  are  white  and  rough,  and  are  termed  leucoplakia. 
They  have  been  well -de  scribed  and  depicted  by  my  colleague, 
Mr.  Butlin.2  Excessive  smoking  is  probably  the  most  frequent 
cause.  According  to  Paget,  the  hard  palate  is  sometimes  thus 
affected,  but  not,  as  is  the  case  in  syphilitic  psoriasis,  the  buccal 
membrane  or  lips.  In  cases  of  acute  and  chronic  gout,  according 
to  Dickinson,3  the  tongue  presents,  as  to  furring  or  coating,  a 
stippled  character,  with  whitish  dots,  or  a  partial  coat,  being 
generally  moist. 

1  Vide  Art.  "  Tongue,"  Quain's  Dictionary  of  Medicine,  1S82,  p.  1638. 

2  Diseases  of  the  Tongue,  1885,  p.  126. 

3  Lumleian  Lectures,  Roy.  Coll    Phys.,  "The  Tongue  as  an  Indication  in  Disease," 
1888,  p.  36. 


88  MORBID  ANATOMY  OF  GOUT. 

Throat  and  Pharynx The  gouty  throat  is  like  no  other.    The 

pillars  of  the  fauces,  especially  the  posterior  pair,  the  velum,  and 
the  uvula,  are  very  red  and  glazed.  They  appear  as  if  freshly 
brushed  over  with  glycerine.  Some  dilated  venules  may  often  be 
seen  coursing  over  parts  of  the  membrane.  The  uvula  is  greatly 
enlarged  and  elongated,  sometimes  seeming  to  fill  up  the  gap  be- 
tween the  pillars.  It  has  often  an  oedematous  border,  or  edging, 
and  tip.  Sometimes  it  is  so  big  that  the  condition  of  the  pharynx 
can  hardly  be  observed.  The  surface  of  the  latter  is  not  so  smooth 
as  that  of  the  fauces.  It  is  coarse,  with  red,  glairy  prominences 
upon  it,  and  depressions  here  and  there  covered  with  greyish, 
slightly  adherent  patches  of  mucus,  and  it  has  sometimes  enlarged 
venules  upon  it.  In  elderly  people  the  redness  is  less  marked  in 
some  instances,  but  the  large  uvula  and  glairy  membranes  are 
readily  recognized. 

A  case  of  granular  pharyngitis  has  been  reported  by  N.  Gueneau 
de  Mussy,1  in  which  masses  of  concretion,  consisting  of  carbonate 
and  urate  of  lime,  were  discharged  several  times  daily.  These 
issued  from  mucous  follicles  which  presented  white  points. 

Angina  tonsillaris,  very  painful,  but  not  suppurating,  may,  in 
the  gouty,  suddenly  yield  to  an  acute  articular  attack.2 

Parotid  Glands. — Gouty  parotitis  is  occasionally  met  with. 
Garrod,  Eotureau,  of  Paris,  Teissier,  of  Lyons,  and  Debout  D'Es- 
trees.3  of  Contrexeville,  have  noted  unequivocal  cases.  Metas- 
tasis to  the  testis  has  not  been  observed  in  this  association. 

Sulpho-cyanide  of  potassium  has  been  found  in  excess  in  the 
saliva  by  Dr.  Fen  wick  in  gouty  patients,  especially  before  an 
acute  attack;  also  in  patients  suffering  from  "bilious  head- 
aches "  who  belonged  to  arthritic  families.4 

Symptoms  referable  to  the  oesophagus  will  be  described  else- 
where. 

Stomach Not  much  is  known  as  to  morbid  anatomy  in  gout  of 

this  organ.  Deposits  of  urates  are  unknown  in  its  mucous  or  other 
coats.  Congestion  and  catarrhal  states  are  found  in  cases  where 
renal  disease  exists,  and  may  fairly  be  referred  to  as  concomi- 
tants of  chronic  nephritis,  and  not  directly  gouty.  Gout  in  the 
stomach  is  often  mentioned,  but  not  often  observed.  The  attack 
is  sometimes  determined  by  irritating  food.  Doubtless,  angina 
pectoris  in  the  gouty  has  been  mistaken  at  times  for  gastric  pain. 

1  L'Union  Me"d.,  No.  xviii.,  1856.     (No  mention  of  "gout"  occurs  in  this  report.) 

2  Case  recorded  by  Sir  H.  Halford,  op.  cit.,  p.  108. 

3  Med.  Chir.  Trans.  Lond.,  vol.  lxx.,  1887,  p.  217, 

4  Med.  Chir.  Trans.  Lond.,  vol.  lxv.,  1882,  p.  127. 


GOUTY    GASTRITIS.       ENTERITIS.  89 

The  most  trustworthy  case  is  one  reported  by  Moxon,1  in  which 
erosion  of  the  mucosa  was  found  with  submucous  haemorrhages 
and  adherent  pellicles  of  lymph,  and  I  have  knowledge  of  another 
in  which  the  symptoms  were  severe,  with  haematemesis  probably 
arising  from  erosion.  The  patient,  aet.  forty-two,  a  medical  man, 
had  had  regular  gout,  inherited  from  his  father.  In  this  cast-  M. 
Charcot  concurred  in  the  diagnosis.2  Many  functional  gastric 
disturbances  occur  in  the  gouty,  such  as  gastralgia,  vomiting, 
sometimes  incoercible,  and  pyrosis.  These  usually  give  way  to 
articular  symptoms,  and  leave  nothing  for  the  morbid  anatomist 
to  discover.  Great  flatulent  distension  may  occur,  with  intense 
pain,  and  this,  together  with  collapse,  may  constitute  the  leading 
symptoms  in  gout  of  the  stomach. 

Pancreas No  noteworthy  changes  have  been  observed  in  this 

organ.      Cancer  is  sometimes  present  in  it  in  the  gouty. 

Intestines Professor  Hayem  has  recorded  a  case  where  enteri- 
tis occurred,  the  villi  being  strewn  with  small  uratic  encrusta- 
tions. In  other  cases  the  enteritic  symptoms  have  appeared  to  be 
dependent  on  associated  nephritis. 

Severe  colic,  tympanitic  distension,  enteralgia,  and  diarrhoea 
are  sometimes  distinctly  referable  to  gouty  disorder  ;  but  little  is 
known  in  respect  of  the  morbid  anatomy  of  such  cases,  since  they 
rarely  prove  fatal. 

Haemorrhoids Tn  the  rectum   haemorrhoids  are    common,  as 

the  result  of  portal  venous  congestion  and  constipation. 

Cutaneous  System. — The  skin  is  not  uniformly  affected  in  per- 
sons of  gouty  habit.  Cullen  says  :  "  Gout  attacks  especially  men 
of  robust  and  large  bodies,  men  of  large  heads,  of  full  and  corpu- 
lent habit,  and  men  whose  skins  are  covered  with  a  thicker  rete 
mucosum,  which  gives  a  coarser  surface."  In  advanced  cases  it 
is  common  to  meet  with  a  peculiar  soft  and  satiny  state  of  skin, 
with  smoothness  as  if  the  integument  had  been  oiled.  This 
is  very  noteworthy  in  the  cases  of  even  labouring  men.  The 
crippling  associated  with  the  fixation  and  pain  in  the  joints  has, 
however,  usually  prevented  any  laborious  pursuit  for  some  time. 
This  smoothness  is  found  especially  marked  on  the  limbs.  The 
facial  integuments  may  be  coarser.  The  capillaries  are  injected 
in  persons  of  the  vascular  arthritic  type.  They  fill  slowly  when 
emptied.      The  nasal  integument  may  become  thick,  coarse,  and 

1  Trans.  Path.  Soc,  1870. 

2  In  the  Hunterian  Museum  there  is  a  preparation  of  a  gouty  stomach  thus 
described: — "A  specimen  of  a  portion  of  the  oesophagus  and  stomach  of  a  person 
who  died  suddenly  of  gout  in  his  stomach.  There  was  considerable  inflammation, 
even  in  some  places  to  the  extravasation  of  blood." 


90  MORBID  ANATOMY  OF  GOUT. 

unctuous,  and  also  unduly  vascular,  with  enlarged  ramifying  ven- 
ules, especially,  but  not  always,  in  tipplers.  These  appearances 
have  been  regarded  as  typical  of  the  meat-eating,  beer-drinking 
Englishman,  the  classical  subject  of  gout.  I  found  three  tophi 
in  the  skin  of  the  nose  in  a  man  aged  sixty-two.  There  were 
none  on  the  ears.  But  gout  attaches  itself  to  almost  all  diatheses, 
and  in  the  pale,  sallow,  or  "  bilious"  subject  (olive-complexioned 
arthritic)  {Lay cock),  with  little-marked  integumentary  vascularity, 
these  changes  (gouty  cachectic)  do  not  so  proceed.  Painful 
follicular  inflammations  in  the  alas  of  the  nose  have  been  noted 
with  some  frequency  in  the  gouty.  These  do  not  suppurate,  but 
are  apt  to  recur  again  and  again.  Skin-diseases  due  to  gout  will 
be  subsequently  treated  of.  The  ears  are  often  large,  and  present 
undue  hardness  in  the  cartilages,  sometimes  in  the  form  of  plates 
of  almost  bony  consistence.1  Tophi  may  or  may  not  be  associ- 
ated with  these.2 

According  to  my  statistics,  in  one  third  (49  in  150)  of  all 
well-marked  cases  of  gout,  the  ears  present  tophi  on  the  helix, 
antihelix  and  its  fossa,  and  the  lobule.  In  many  cases  where 
deposits  exist  in  joints,  there  may  be  entire  absence  of  tophi  in 
the  ears  or  other  peripheral  parts.  With  less  frequency  deposit 
is  found  in  the  skin  away  from  joints,  and  here  almost  indiscrimi- 
nately. Thus,  tophi  have  been  found  in  the  alee  of  the  nose,  in 
the  integument  of  the  trunk,  perineum,  and  penis,  over  the  ulna 
and  tibia,  and  are  common  over  the  olecranon  and  patella.  The 
palmar  integument  and  pulps  of  the  fingers  are  not  infrequent 
sites. 

These  tophi  sometimes  burst  and  discharge,  or  may  be  picked 
out,  especially  from  the  ears,  in  small  chalky  masses.  In  one  case 
they  disappeared  from  the  ears,  and  had  not  returned  after  three 
years,  the  patient  having  given  up  beer  in  the  meantime.  Tophi 
are  very  rare  in  the  ears  of  women.  I  demonstrated  an  instance 
of  this  in  a  series  of  gouty  cases  at  the  International  Medical 
Congress  in  London  in  188  I.3  In  a  remarkable  case  under  my 
care  in  1888,  where  tophi  were  most  widely  diffused,  they 
occurred  in  streaks  on  the  eyelids,  much  resembling  xanthoma. 

1  To  these  plates  I  would  apply  the  term  porosis,  which  comes  down  from  Galen 
in  connection  with  gout. 

2  Vide  a  case  recorded  by  me  in  Clin.  Soc.  Trans.,  vol.  xvi.  p.  258,  1883.  Dr. 
Barlow  has  made  two  similar  observations. 

3  Transactions,  1881.     Report  on  Congress  Museum,  p.  124. 

4  "  In  mercatore  podagrico  diu  et  misere  afflicto  ex  toto  corpore,  per  poros,  adeo  ut 
etiam  palpebral  oculorum  non  exemptse  fuerint,  ejusmodi  materiam  gypseam,  circa 
poros  cutis  mox  in  tophos  mutatam  prodiisse  observavit." — F.  Plater,  Prax.  Med. 
torn.  ii.  p.  598. 


CUTANEOUS    SYSTEM.       TOPHI.  9  I 

These  were  chemically  tested,  and  proved  to  be  uratic  (vide  Plate, 
fig.  i).  When  they  are  seen  on  the  face  and  ears,  they  have 
sometimes  to  be  distinguished  from  milium  and  small  sebaceous 
cysts.  Tophi  have  been  found  in  the  sclerotic  tissue  of  the  eyeball. 
They  tend  to  produce  irritation  of  the  skin,  which  becomes  pur- 
plish, thin,  transparent,  and  glossy,  and,  lastly,  ulcerates.  A 
fungous  base  is  seen  with  uratic  discharge.  Such  ulcers  occur 
on  the  hands,  feet,  and  legs.  In  the  latter  situation  they  may 
be  complicated  with  varix,  and  are  apt  to  be  painful. 

Sub-acute  gout  sometimes  occurs  in  the  ears,  and  I  believe 
the  indurations  of  the  cartilage  I  have  noted  to  be  the  result  of 
such  attacks.  Laycock  described  the  lobule  of  the  ears  in  per- 
sons of  the  gouty  habit  as  "  soldered,"  that  is,  not  pendulous. 
It  is  often  plump  and  vascular,1  and  tophi  may  occur  in  it. 

Hair. — The  hair  is  thick  in  early  life,  but  often  tends  to  grow 

1  Physiognomy  of  the  Goutily  Disposed. — Taking  the  principles  as  laid  down  by  Lay- 
cock,  the  peculiarities  of  those  thus  affected  fall  under  the  head  of  the  sanguine  arthritic 
diathesis.  (That  careful  observer  did  not  fail  to  note  the  modifying  influences  of 
gout  upon  struma  and  other  cachexia.)  Thus  may  be  compared  the  physiognomy  of 
the  diathesis  and  its  associated  cachexia  (developed  in  time)  : — 

Blood-vessels  numerous  ;  heart  large  and  powerful  ;  blood-corpuscles  numerous  ; 
skin  over  malar  bones  highly  vascular  (florid  complexion)  ;  skin  fair,  firm,  oleaginous, 
perspirable  ;  eyes  blue  ;  hair  thick,  not  falling  easily  ;  teeth  massive,  well-enamelled, 
regular,  even,  undecayed  in  advanced  life  ;  malar  bones  flattened  ;  head  symmetri- 
cal ;  nasal  bones  well-formed,  nose  aquiline  or  of  mixed  form  ;  lower  jaw  massive  ; 
lips  symmetrical. 

Form. — Figure  for  the  most  part  tall ;  thorax  broad  at  the  summit ;  ribs  well- 
curved  ;  abdomen  full  ;  muscles  firm,  large  ;  limbs  large,  robust  ;  gait  erect,  well- 
poised.  Nutrition  active  ;  digestion  vigorous  ;  appetite  great  for  animal  food  and 
alcoholic  stimuli.  Respiration  deliberate,  deep  ;  circulation  vigorous  ;  animal  heat 
abundant  ;  locomotion  active  ;  aptitude  for  exercise  and  outdoor  amusements. 
Reproductive  powers  active  ;  innervation  abundant ;  the  mental  powers  vigorous 
and  enduring. 

Physiognomy  of  the  Sanguine  Gouty  Cachexia. — Blood-vessels  largely  developed 
over  the  malar  bones  and  varicose  ;  skin  oily,  yellow  from  subcutaneous  deposit 
of  fat ;  hair  thick  and  white  ;  teeth  numerous,  discoloured,  crusted  with  tartar ; 
lips  bluish,  nose  reddish,  hypertrophied  ;  arcus  senilis ;  abdomen  pendulous  ;  limbs 
thick  ;  joints  nodose  ;  nodosities  on  the  ends  of  the  fingers,  lobes  of  ears,  fascia  of 
muscles,  and  tendons ;  respiration  hurried,  wheezing  ;  pulse  intermittent,  irregular ; 
stomach  flatulent ;  digestion  acid  ;  urine  loaded  with  lithates  ;  temper  irritable  ; 
mind  sometimes  enfeebled. 

The  local  diseases  of  the  arthritic  cachexia  are  principally  seen  in  adult  males  past 
the  age  of  forty-five.  They  consist  especially  in  chronic  inflammation  of  the  muscular 
and  articular  tissues  ;  in  calcification  of  the  basilar  and  coronary  arteries,  and  of  the 
cardiac  valves.  These  changes  give  rise  to  hsemorrhagic  apoplexy,  angina  pectoris, 
cardiac  hypertrophy  and  dilatation  :  and  to  secondary  pulmonary  affections,  as  emphy- 
sema, pulmonary  apoplexy,  and  asthma.  Irritation  of  the  mucous  surfaces  may  give 
rise  to  nephritis,  pharyngeal  and  laryngeal  coughs,  and  diarrhoea.* 

*  Med.  Observation  and  Research,  2nd  edit.,  pp.  96-98. 


92  MORBID  ANATOMY  OF  GOUT. 

thin  on  the  vertex  before  the  third  decade,  and  may  leave  a  shiny- 
poll  with  a  well-defined  ring  of  hair  below.  In  some  cases  there 
is  early  greyness  in  the  goutily  disposed,  and  abundant  grey  hair 
may  be  maintained  through  life.  In  others  the  hair  retains  luxu- 
riance and  good  colour  to  the  seventh  or  eighth  decade,  even 
with  profound  articular  disease  and  deposits.  These  facts  are 
founded  on  many  careful  observations,  hence,  no  special  type  can 
be  described  in  respect  to  the  nutrition  of  the  hair.  The  marked 
divergence  must  be  explained  by  factors,  personal  or  inherited,  in 
each  case.  Greyness  goes  with  general  tissue-failure,  as  a  rule, 
but  this  is  found  to  vary  much  even  in  the  same  family,  and  it 
must  be  borne  in  mind  that  in  some  persons  certain  textures  tend 
to  decay,  and  die  out  sooner  than  others.  This  is  equally  true  of 
the  teeth,  and  yet  in  each  case  longevity  may  occur. 

The  composition  of  tophaceous  matter  or  "  cutaneous  gravel," 
as  Trousseau  termed  it,1  has  been  found  to  vary  in  respect  of  the 
sodium  and  calcium  salts  of  uric  acid,  according  to  the  site  whence 
it  is  taken,  but  about  fifty  per  cent,  of  it  is  uratic,  and  sodium 
chloride  is  present  to  the  extent  of  ten  per  cent.  Calcium 
phosphate  and  animal  matter  make  up  the  remainder.  The  con- 
sistency varies,  according  to  its  age,  from  that  of  cream  to  that 
of  ordinary  chalk.  Sir  A.  Garrod  gives  me  his  experience  to  the 
effect  that  tophi  consist  essentially  of  crystallized  sodium  urate, 
which  can  be  dissolved  in  distilled  water  and  re-crystallized,  and 
he  believes  that  lime  is  only  an  accidental  admixture.  In  cardiac 
valvular  concretions  occurring  in  the  gouty,  there  appears  to  be 
only  slight  impregnation  of  lime-salts  with  urates. 

Sir  Andrew  Clark  has  told  me  of  a  case  in  which  analysis 
of  tophus-matter  yielded  a  large  amount  of  calcium  oxalate,  and 
he  believes  that  calcium  urate  in  spiculated  crystals  is  common  as 
a  deposit.  A  specimen  of  tophus  from  the  patellar  bursa  of  one 
of  my  patients  was  kindly  examined  by  my  colleague,  Dr.  Russell, 
in  the  Laboratory  at  St.  Bartholomew's  Hospital,  and  was  found  to 
consist  essentially  of  sodium  urate  with  a  mere  trace  of  calcium  salts. 

The  skin  is  usually  active  in  respect  of  sweating,  though  when 
exercise  is  lessened  from  any  cause,  and  in  cold  weather,  it  may 
be  very  inactive.  It  has  been  maintained  that  urates  do  not  pass 
off  from  the  sweat-glands.  Garrod  has  emphatically  declared 
this,  but  Drs.  Meldon  and  Tichborne,  of  Dublin,  are  equally 
confident  in  affirming  the  contrary.  The  latter  has  indicated  the 
best  method  for  detecting  uratic  salts  in  sweat.2      I  have  had 

1  "  Tartar  of  the  blood." — Sydenham. 
-  Brit.  Med.  Journal,  November  19,  1887,  p.  1097. 


BUIiSiE.       NAILS.       TEETH.  93 

several  experiments  made  to  determine  this  question,  so  far 
without  any  success.  The  relief  afforded  in  gouty  cases  by 
regular  use  of  Turkish  baths  is  attributed  to  the  free  action  of 
the  skin.  These  are  probably  effective  in  much  the  same  way 
as  is  regular  muscular  exercise,  and,  in  great  measure,  they  may 
replace  this,  especially  if  followed  up  by  shampooing. 

Golding  Bird  found  uric  acid  in  the  contents  of  the  vesicles  of 
gouty  eczema,  and  James  Begbie  recorded  an  instance  of  pem- 
phigus in  which  uric  acid  was  found  in  the  fluid  of  the  bullae. 

The  skin-diseases  to  which  the  gouty  are  especially  obnoxious 
are  eczema  and  psoriasis,  and  these  will  be  discussed  elsewhere. 

The  bursas  over  the  joints,  especially  of  the  knuckles  and 
phalanges,  are  apt  to  be  loose  and  enlarged,  and  are  recognized 
sites  for  uratic  deposits.  That  over  the  olecranon  is  sometimes 
distended  to  the  size  of  a  large  orange,  and  nodules  of  urates  can 
be  felt  in  it,  as  well  as  increase  of  synovia. 

Nails. — The  nails  are  observed  to  be  coarse  and  fibrous,  striated 
and  fluted,  or  lined  vertically.  Vide  Figs.  13-16.  This  peculiarity 
is  well-marked  in  most  persons  of  the  arthritic  diathesis,  and  hence 
is  found  in  rheumatic  persons.  The  nail- substance  is  apt  to  grow 
thick  and  brittle,  and  especially  so  after  attacks  of  gout.  The 
nails  may  be  shed  after  severe  local  attacks. 

The  transverse  depressions,  described  by  M.  Beau  and  by  Dr. 
Wilks,  are  seen  in  due  time  after  gouty  as  after  other  illnesses, 
indicating  a  temporary  failure  and  depression  of  nutrition  of  the 
whole  body.  As  an  entire  nail  takes  six  months  to  grow,  the 
site  of  these  furrows  indicates  the  date  of  the  past  illness  with 
singular  exactness.      Sometimes  a  white  line  marks  the  attack. 

Teeth. — The  teeth  are  especially  noteworthy  in  persons  of  gouty 
habit.  They  are,  as  a  rule,  well  developed,  with  strong  and  hard 
enamel  which  is  rather  yellow  in  colour.  They  resist  decay  and 
are  firmly  set  in  their  alveoli.  In  time  they  become  more  or  less 
worn  down,  so  that  the  pulp-cavities  begin  to  be  visible.1 

Buck-teeth  are  not  uncommon,  one  of  the  lower  central  incisors 
being  thrust  out  of  rank,  as  first  noticed  by  Laycock.  I  have 
observed  these  characters  in  a  large  number  of  cases,  and  am  con- 
firmed as  to  their  correctness  by  dental  surgeons.2 

1  Pye-Smith  quotes  the  authority  of  Mr.  Moore  for  the  facts  that  this  condition 
may  be  caused  by  that  formation  of  jaws  which  gives  an  edge-bite,  also  in  cases 
where  the  enamel  is  thin  on  the  summits  of  the  teeth. — Fagge,  Prin.  and  Pract.  of 
Med.,  2nd  edit.,  p.  490. 

2  Vide  "  The  Characters  of  the  Teeth  in  Persons  of  the  Arthritic  Diathesis,"  a 
paper  read  by  myself  before  the  Odoutological  Society  of  Great  Britain,  in  Soc. 
Journal,  1883,  p.  193. 


94  MORBID  ANATOMY  OF  GOUT. 

A  tendency  to  shed  sound  teeth  has  been  noted  with  some  fre- 
quency in  middle  or  later  life  in  goutily  disposed  persons,  and 
they  are  more  than  others  liable  to  occasional  and  fugitive  attacks 
of  pain  in  several  sound  teeth  at  a  time,  with  a  sensation  as  if 
these  were  starting  from  their  sockets,  being  tender  to  bite 
upon.1 

Without  doubt,  many  varieties  may  be  met  with  in  the  char- 
acters I  have  laid  down.  These  are  explicable  by  the  fact  that 
other  causes  are  at  work  unconnected  with  gouty  influence,  and 
with  other  commingled  diathetic  states  are  found  the  tendencies 
and  results  of  those  states.  This  statement  holds  good  for  all 
tissue-characteristics  that  may  be  affirmed  of  the  gouty.  I  am 
only  concerned  here  to  express  the  prominent  and  typical  fea- 
tures that  may  be  observed,  and  to  describe  the  character  that 
pertains  to  the  several  tissues  as  impressed  by  the  gouty  habit  of 
body. 

My  statements  are  chastened  by  the  discipline  entailed  by 
long- continued  and  careful  inquiiy  on  these  points. 

It  may  be  confidently  affirmed  that  no  uratic  deposits  are 
met  with  in  connection  with  the  jaws,  teeth,  or  gums,  notwith- 
standing contrary  statements. 

Tooth-grinding,  as  a  peculiarity  of  the  gouty,  will  be  subse- 
quently referred  to. 

Eye. — Iritis  is  met  with  in  the  gouty,  and  is  believed  to  be  a 
manifestation  of  this  habit.  It  may  be  very  insidious,  and  is 
prone  to  relapse.  Gouty  persons  are  more  than  others  apt  to 
suffer  from  glaucoma,  which,  as  Mr.  Nettleship  remarks,  was 
formerly  described  as  "  arthritic  ophthalmia."  This  is  commoner 
in  women  during  pregnancy  or  soon  after  the  menopause.  Males 
thus  affected  are  often  subject  to  haemorrhoids.  Mr.  Hutchin- 
son 2  has  described  cases  of  hemorrhagic  retinitis. 

Hsemorphagie  Retinitis — This  occurs  usually  in  one  eye,  and 
is  of  sudden  onset  in  the  gouty  or  in  persons  so  predisposed. 
It  is  to  be  differentiated  from  albuminuric  retinitis.  Small 
flame-shaped  patches  of  hemorrhage  are  scattered  abundantly 
over  the  fundus.  Those  which  are  punctate  have  striated  mar- 
gins, and  none  appear  as  blots.  Haziness  about  the  disc  is 
observed,  but  no  glistening,  white  deposits  as  met  with  in 
renal  retinitis.  The  veins  are  large  and  angular  from  tumes- 
cence, and  rendered  indistinct  by  blood- effusion  into  their 
sheaths.     The  arteries  are  very  small.      Of  fifteen  cases  noted  by 

1  Vide  cases  reported  by  Mr.  James  Rymer,  Jour.  Brit.  Dent.  Assoc,  August 
18S7,  p.  499.  2  Clin.  Soc.  Trans.,  vol.  xi.  p.  132,  1878. 


EYE.       HEMORRHAGIC    RETINITIS.       GLAUCOMA.  95 

Hutchinson,  eleven  occurred  in  men  and  four  in  women.  The 
youngest  patient  was  forty-four,  the  oldest  seventy-two,  and 
seven  were  over  sixty  years.  Gout  was  positively  present  in  six, 
and  was  strongly  probable  in  four  or  five  others.  In  one  there 
was  saturnine  gout,  with  much  albuminuria ;  and  in  another 
there  was  no  gouty  history,  but  diabetes  existed,  which  was  pro- 
bably the  cause  of  retinitis.  In  ten  cases  only  one  eye  was 
affected,  and  in  five  both.  In  about  one-third  of  the  cases 
there  was  slight  albuminuria  present  occasionally.  There  was  no 
dropsy. 

As  Mr.  Hutchinson  observes,  it  is  hardly  justifiable  to  separate 
this  group  of  cases  abruptly  from  other  forms  of  retinitis  asso- 
ciated with  renal  disease  and  diabetes,  since  kidney-disease  is  so 
often  a  concomitant  in  gouty  cases.  The  main  points  to  be  noted 
are  the  unilateral  character,  the  left  eye  being  most  often  affected, 
the  very  numerous  flame-shaped  haemorrhages,  and  the  absence 
of  white  deposits.  The  extravasations  may  recur  for  a  long 
period. 

The  influence  of  the  cardio-vascular  system  must  be  considered 
in  relation  to  the  occurrence  of  retinitis.  Haemorrhages  may  arise 
under  the  influence  of  strain,  as  in  stooping  or  coughing.  Mr. 
Hutchinson  is  of  opinion  that  this  form  of  retinitis  is  due  rather 
to  venous  obstruction,  such  as  thrombosis  of  the  retinal  vein,  than 
to  arterial  disease,  the  former  being  a  recognized  gouty  lesion, 
and  better  explanatory  of  the  suddenness  of  the  attacks  than  a 
theory  of  arterial  embolism  or  aneurysm. 

I  am  inclined  to  regard  these  haemorrhages  as  being  sometimes 
akin  to  the  subconjunctival  bleedings,  epistaxis,  and  other  leak- 
ages from  small  vessels  which  are  very  apt  to  occur  in  those  of 
gouty  habit. 

Oases  of  insidious  irido-cyclitis,  leading  to  secondary  glaucoma, 
have  been  noted  by  Mr.  Hutchinson  as  sometimes  occurring  in 
the  members  of  gouty  families  during  early  adult  life. 

Conjunctivitis,  episcleritis,  and  sclerotitis  are  recognized  as 
of  gouty  origin.  Garrod  found  uratic  deposit  in  two  cases  on 
the  conjunctivae. 

Glaucoma. — Mr.  Brudenell  Carter  has  noted  the  tendency  of 
iritis  or  keratitis  in  arthritic  cases  to  spread  to  the  anterior  scle- 
rotic (vascular)  zone  around  the  cornea.  He  is  of  opinion  that  a 
large  number  of  examples  of  supposed  gouty  or  rheumatic  oph- 
thalmia are  nothing  more  than  cases  of  subacute  or  remittent 
forms  of  glaucoma,  the  pain  being  tensive  and  not  specific. 

The   point  to   be   noted,   however,   is  the   tendency  for  those 


96  MORBID  ANATOMY  OF  GOUT. 

arthritically  disposed  to  suffer  from  this  special  class  of  ailment 
with,  greater  frequency  than  those  not  thus  impressed. 

Optic  Neuritis. — There  are  no  proofs  that  optic  neuritis  is  ever 
of  gouty  origin.  Mr.  Hutchinson,  however,  believes  that  he  has 
met  with  cases. 

A  case  of  destructive  inflammation  of  the  eyeball  in  a  gouty 
man  is  mentioned  by  Mr.  Stephen  Paget  as  having  occurred  in 
Mr.  George  Critchett's  practice.1  There  had  been  history  of 
gout  for  twenty-three  years.  At  last  he  had  inflammation  of  the 
right  eye,  which  recurred  more  than  once ;  then  came  acute 
destructive  inflammation,  with  suppuration  of  the  globe,  the  scle- 
rotic gave  way,  the  lens  escaped,  and  the  globe  collapsed. 

Blocking  of  the  duct  of  a  Meibomian  gland  leading  to  a  pro- 
jection on  the  inner  aspect  of  the  tarsal  cartilage,  and  thus  irri- 
tating the  conjunctiva,  is  alleged  by  Brudenell  Carter  to  occur 
most  often  in  the  gouty,  the  retained  secretion  being  rendered 
more  irritant  by  chalky  deposit/ 

Lymphatic  System. — The  lymphatic  system  has  been  held  to 
be  free  from  any  changes  in  gout.  The  glandular  portion  cannot 
be  said  to  be  involved,  but  there  is  clinical  evidence  of  sub-acute 
gouty  inflammation  of  lymph-spaces  in  certain  regions,  due  to 
uratic  deposit  and  influence.  Dr.  Buzzard  has  called  attention 
to  this.3 

Spleen The  spleen  cannot  be  said  to  be  specifically  affected. 

In  many  cases  it  is  enlarged  and  hard  in  texture,  and  may  reach 
from  15  to  22  ounces  in  weight.  Sometimes  it  is  found  to  be 
soft.  Infarctions  are  met  with  occasionally,  and  adhesions  may 
exist  between  it  and  the  stomach  and  diaphragm.  The  capsule  is 
not  infrequently  thickened.  Most  of  these  changes  are  not  impro- 
bably in  relation  with  the  associated  cardiac  and  hepatic  conditions. 

Adrenal  Bodies. — No  changes  have  been  noted  in  the  supra- 
renal glands. 

Ear. — But  little  has  been  recorded  respecting  the  morbid  ana- 
tomy of  the  ear  in  gout.  The  auditory  meatus  is  sometimes  found 
red,  glazed,  and  as  if  recovering  from  eczema.  According  to  Hin- 
ton,  "  a  peculiar  irritation  of  the  meatus  with  dull  redness,  swell- 
ing, and  watery  discharge  resisting  local  remedies  are  very  charac- 
teristic of  gout."      Mr.  Hutchinson  prefers  the  term  seborrhcea 

1  Clin.  Soc.  Trans.,  vol.  xx.  p.  234,  1887. 

2  Holmes' Surgery,  p.  692.    So  far  as  I  am  aware,  this  has  not  been  proved  chemically. 

3  Diseases  of  Nervous  System,  p.  69,  1882. 

"  The  fasciae  and  other  fibrous  structures  are  nothing  but  lymphatic  pumps,  pump- 
ino-  up  the  waste  material  from  the  muscles  and  sending  it  on  into  the  lymphatic 
trunks." — L.  Brunton,  Disorders  of  Digestion,  p.  231,  1S86. 


EAR.   MUSCULAR  AND  NERVOUS  SYSTEMS.       97 

for  these  cases.1  In  a  chronic  form  this  may  last  for  many 
years,  leading  to  hypertrophy,  and  so  to  stenosis  of  the  canal, 
admitting  barely  a  small  eye-probe. 

Sir  William  Dalby  has  kindly  reported  to  me  instances  of  this 
kind.  Attacks  of  acute  gout  may  occur  in  the  external  canal, 
yielding  to  specific  treatment.  This  form,  according  to  Dalby, 
does  not  involve  the  membrane  or  tympanic  cavity,  but  the 
swelling  may  be  so  great  as  nearly  to  occlude  the  canal.  The 
auricle  is  sometimes  thus  affected. 

Tophi  have  already  been  referred  to  as  occurring  in  the  pinna. 
More  rarely  they  occur  on  its  posterior  aspect.  If  the  ear  be 
held  out  against  sunlight  or  a  beam  of  lamp-light,  the  distribu- 
tion of  the  deposits  is  well  seen.  The  large,  so-called,  calcareous 
deposits  in  the  tympanic  membrane  often  seen,  can  in  no  way, 
so  Dalby  believes,  be  connected  with  gout.  They  occur  some- 
times in  children,  and  are  commonly  cicatricial  results  of  per- 
foration. 

Multiple  hyperostosis  of  the  canal  has  been  attributed  to  gout, 
but,  according  to  Dalby,  without  sufficient  reason.  Adhesive 
changes  and  thickenings  of  the  ossicula,  when  met  with,  can 
only  be  regarded  as  results  of  inflammatory  processes,  and  not 
as  certainly  gouty  in  most  cases.  Uratic  deposits  have  not  been 
found  on  the  ossicula.  I  have  already  noted  the  liability  to 
induration  of  the  cartilage  of  the  auricle  in  gouty  men,  and  the 
occurrence  of  flattened  nodular  masses  in  them,  which  I  term 
porosis. 

It  is  probable  that  some  forms  of  senile  deafness  are  attribut- 
able to  gouty  changes  in  the  ossicula. 

Muscles. — There  is  no  recognized  morbid  change  in  the  mus- 
cular system.  Uric  acid  has  been  found  in  the  muscles.  Tendons 
become  involved  in  association  with  the  joints,  uratically  en- 
crusted and  stiffened.2  The  muscles  are  the  sites  of  painful  gouty 
attacks  and  of  subjective  symptoms  in  the  gouty.  These  will  be 
elsewhere  described.  That  much  so-called  "  muscular  rheuma- 
tism "  is  really  gouty,  I  feel  sure. 

Nervous  System. — In  respect  of  the  nervous  system,  it  may  be 
affirmed  that  there  is,  as  yet,  no  morbid  anatomy  in  the  gouty. 
The  changes  due  to  cachexia  in  long-standing  cases  are  not 
now  in  question.  Clinically,  there  is  good  reason  to  believe  that 
gout  may  induce  neuritis  in  almost  any  nerve-trunk  with  motor, 

1  Med.  Press  and  Circular,  January  25,  1888,  p.  77. 

2  Rupture  of  the  tendo  Achillis  is  stated  by  Gairdner  to  occur  chiefly  in  persons 
of  gouty  habit.     It  is  an  accident  of  advanced  life.     Op.  cit.,  p.  26. 

G 


98  MORBID    ANATOMY    OF    GOUT. 

sensory,  and  vaso-motor  symptoms.  Dr.  Buzzard  lias  directed 
attention  to  the  manner  in  which  this  is  probably  set  up  through 
the  lymph-spaces  in  connection  with  the  nerve-bundles  wherein 
uratic  deposits  may  form.  Neuralgia  is  especially  common  in  the 
gouty.  Cases  of  sciatica,  and  affections  of  the  circumflex,  median, 
and  portio  dura  are  now  well-recognized,  and  have  been  referred 
to  gout  by  Todd.1  Dr.  Buzzard 2  relates  a  case  of  pseudo-infan- 
tile paralysis  due  to  neuritis.  Dr.  Ormerod  has  recorded  cases  of 
tingling  and  numbness  in  the  arms  in  connection  with  gout  and 
knobby  joints.3  I  have  seen  many  such.  Perineuritis  is  pro- 
bably the  lesion,  and  there  may  be  much  pain. 

More  important  than  these,  however,  are  cases  of  gouty  para- 
plegia, which,  though  rare,  occur  in  men  past  middle  life,  some- 
times suddenly  as  by  metastasis  from  a  joint.  The  paralysis  may 
be  complete  and  involve  the  sphincters.  Such  cases,  happily, 
recover,  and  leave  no  subsequent  changes.  Occasionally,  the  para- 
lysis yields  suddenly  to  onset  of  arthritic  gout. 

It  is  rare  to  find  uratic  deposit  in  the  nervous  tissues  or  their 
investments.  They  have  been  detected  on  the  cerebral  meninges 
in  a  few  instances,  and  sodium  urate  was  found  by  Cornil  in  the 
cerebro-spinal  fluid.  On  the  spinal  meninges  deposits  have  been 
found  by  Albert  and  Ollivier.  The  latter  has  recorded  an  im- 
portant case  in  a  gouty  man,  set.  forty-five,  in  which  fulgurant  pains 
of  locomotor  ataxia  were  supposed  to  exist.  There  were  constric- 
tive pains  round  the  neck,  chest,  and  abdomen,  with  radiation 
down  the  limbs.  Uratic  deposits  were  found  outside  the  spinal 
dura  mater.  A  patch  of  whitish  granulations  was  found  on  this 
membrane,  extending  from  the  third  cervical  vertebra  to  the 
sacral  canal,  being  thickest  in  the  mid-dorsal  region  and  extend- 
ing along  the  sheaths  of  the  spinal  nerves.  This  was  only  sepa- 
rable by  tearing.  The  chord  and  other  membranes  were  unaffected. 
M.  Rendu,  who  relates  this  case,  remarks  that  the  dura  mater  is 
the  least  vascular  of  the  meninges. 

Charcot 4  found  uric  acid  in  the  sub-arachnoid  fluid  of  a  gouty 
woman  by  means  of  Garrod's  thread-test. 

Graves  believed  that  gouty  degeneration  of  the  spinal  chord 
occurred  sometimes,  following  neuralgia,  neuritis,  and  perineuritis 
spreading  centripetally.  He  remarked  that  "  there  is  no  reason 
why  gout  should  not  attack  the  spinal  marrow  and  its  investing 

1  Clin.  Lectures,  Nervous  Diseases,  pp.  69,  72. 

2  Nervous  Diseases,  p.  39. 

3  St.  Barth.  Hosp.  Reports,  vol.  six.   1883. 

4  Arch,  de  Phys.,  2  Ser.,  vol.  v.  p.  455,  1878. 


KIDNEYS.       NEPHRITIS    ARTHBITICA.  99 

membranes  in  the  first  instance,  or  in  consequence  of  metastasis.1 
All  that  can  now  be  affirmed,  half  a  century  since  this  was  written, 
is  that  such  cases  are  of  extreme  rarity,  and  that  little  has  come 
to  light  in  respect  of  their  morbid  anatomy. 

Kidneys. — Perhaps  no  part  of  the  morbid  anatomy  of  gout  is 
of  more  importance  than  that  relating  to  the  kidneys.  A  large 
conception  of  gout  demands  attention  not  merely  to  the  changes 
associated  with,  and  dependent  on,  uratic  deposition,  as  has  already 
been  set  forth  in  these  pages.  We  have  to  deal  clinically  with 
other  manifestations  than  these,  and  with  none  of  more  profound 
significance  than  those  affecting  the  kidneys.  I  must  here  reaffirm 
my  belief  that,  either  by  the  influence  of  the  gouty  poison  directly, 
or  by  inherent  tissue-proclivities  peculiar  to  those  goutily  disposed, 
changes  occur  in  various  organs  and  parts  which  can  in  no  overt 
way  be  shown  to  be  due  to  uratic  deposits.  This  is,  in  truth, 
part  of  the  pathology  of  gout.  The  constant  experience  of  the 
dead-house  is  against  such  direct  deposition  in  the  majority  of 
cases  of  so-called  gouty  kidneys.  A  more  important  question  to 
determine  in  such  cases  is  the  presence  of  uratic  deposit  elsewhere 
in  the  body,  and  especially  in  some  joint.  It  is  still  too  common 
to  hear  small  granular  kidneys  called  "  gouty"  kidneys.  I  enter- 
tain no  doubt  that  forms  of  interstitial  nephritis  occur  which  owe 
no  dependence  on  gout,  but  I  am  equally  convinced  that  the 
kidneys  may  be  primarily  or  mainly  affected  in  some  cases  with 
gouty  disease  which  leads  to  chronic  nephritis  and  a  small, 
granular  condition  of  these  organs.  This  opinion  is  founded 
partly  on  clinical  considerations  and  partly  from  a  study  of  the 
aetiology  of  these  cases.  If  it  can  be  shown,  as  I  think  it 
can,  that  in  gouty  families  certain  members  suffer  from  the 
primary  articular  form  of  the  disease,  while  others  show  signs 
of  renal  change  alone,  apart  from  joint- affections,  and  the 
autopsy  reveals  the  characteristic  conditions  of  such  nephritis  as 
is  common  in  chronic  gout  with  joint-lesions,  I  think  the  case 
is  proved. 

The  abiding  weak  point  in  the  argument  is  the  difficulty 
which  arises  in  consequence  of  incomplete  examination  of  the 
joints  for  evidence  of  deposit.  This  may  perhaps  be  fairly  con- 
ceded, because  it  is  certain  that  quiet  deposits  may  occur  in  joints 
without  giving  any  token  of  their  presence  during  life,  and  hence 
there  is  no  history  of  overt  gout  in  such  instances.  Again,  it  is 
equally  certain  that  gout  may  occur  in  joints  and  leave  behind  no 

1    Vide  two  cases  reported  in  his  Clin.  Med.,  reprint  from  2nd  edit,   by  Neligan, 
P.  367. 


IOO  MORBID  ANATOMY  OF  GOUT. 

uratic  deposits.  An  appeal  to  such  statistics  as  are  alone  of  value 
for  this  purpose  gives  the  following  results  :  — 

Drs.  Orel  and  Greenfield 1  found,  in  a  series  of  cases  examined 
with  a  view  to  determine  the  presence  or  absence  of  renal  disease 
in  association  with  uratic  deposits,  that  in  two-thirds  of  these 
hospital  cases  of  gouty  affection  of  the  great  toe-joint,  there  was 
a  definite  co-existence  of  contracted  granular  kidney,  and  in 
the  remaining  third  there  were  affections  of  the  kidney  closely 
allied  thereto.  There  were  at  least  eight,  and  probably  nine,  out 
of  ninety-six  cases  of  renal  disease  in  which  no  uratic  deposits 
were  found  in  the  joints.  Of  these,  two  were  examples  of  extreme 
granular  contraction,  two  of  marked  contracted  gra.nidar,  two  of 
slightly  granular,  and  one  of  mixed  granular  and  tubal  nephritis. 

Dr.  Norman  Moore 2  gives  a  table  of  forty-nine  cases  of 
chronic  interstitial  nephritis  in  males,  and  shows  that  uratic 
deposits  were  present  in  twenty-two  cases.  The  youngest  was 
twenty-eight  years  of  age,  the  oldest  sixty-six,  the  mean  age 
forty-nine  years.  He  gives  another  of  sixteen  cases  in  females, 
in  which  urates  were  present  in  five  cases.  The  youngest  was 
thirty-four  and  the  oldest  sixty-six  years,  the  mean  age  fifty-one 
years.  In  nine  cases  of  chronic  parenchymatous  nephritis  in 
males,  he  found  deposits  in  the  joints  in  two  cases  at  the  ages 
of  thirty-eight  and  forty  years.  In  two  cases  in  females  he 
found  no  deposits.  With  respect  to  the  former  cases,  he  remarks 
that  "  chronic  interstitial  nephritis  is  not  invariably  accompanied 
by  deposits  in  the  articular  cartilages,  though  usually  accom- 
panied by  some  traces  of  degeneration  in  some  of  the  articular 
cartilages." 

Dr.  Pye-Smith  records  ten  fatal  cases  of  gout  in  men.3  Ex- 
cluding two  cases  in  which  malignant  disease  was  the  immediate 
cause  of  death,  the  mean  age  was  about  forty-eight.  There  was 
interstitial  nephritis  in  all  the  cases,  save  the  cancerous,  and 
cerebral  hemorrhage  occurred  in  two  cases,  one  aged  thirty-eight 
and  the  other  sixty. 

In  sixty-nine  fatal  cases  of  granular  kidney  Dr.  Dickinson 
found  sixteen  dependent  on,  or  coincident  with,  gout.4  The 
change  he  regards  as  gout  of  the  kidney.  No  examination  of 
joints  is  recorded. 

Virchow 5  is  inclined  to  believe  that  there  can  be  a  gouty 
nephritis  without  either  classical  gout  or  uratic  depositions. 

1  Trans.  Iuternat.  Med.  Congress,  London,  1881,  p.  107. 

2  hoc.  cit.,  p.  292.  3  Guy's  Hosp.  Rep.,  1874. 

4  Pathol,  and  Treat,  of  Albuminuria,  p.  149,  1877.  5  Op.  cit.,  p.  149. 


VARIETIES    OF    INTERSTITIAL    NEPHRITIS.  IOI 

It  is  certain  that  gout  may  occur  in  the  ordinary  articular 
form  without  implicating  the  kidneys,  which  may  remain  healthy 
even  into  advanced  life.  In  such  cases  there  is  usually  a  fine 
constitution,  great  resistance  and  vigour  of  the  tissues ;  and  the 
progress  of  the  disease  is  kept  at  bay  and  overcome  by  the  vital 
organs.  In  primary  renal  gout  the  general  health  is  poor,  and  a 
progressive  cachexia  works  its  special  ravages,  cutting  life  .short 
prematurely.  In  frank  gout  of  long  duration  the  kidneys  com- 
monly undergo  gradual  cirrhotic  changes,  but  exceptional  cases 
are  met  with,  as  stated  above.1 

The  changes  induced  are  essentially  chronic,  insidious  in  origin, 
and  not  recognized  till  mischievously  advanced.  I  believe  that 
the  gouty  habit  is  alone  the  potent  aetiological  factor  in  a  con- 
siderable proportion  of  all  cases  of  interstitial  nephritis,  the  form 
in  which  this  manifestation  occurs. 

The  influence  of  lead-impregnation  and  of  alcoholic  intemper- 
ance on  the  production  of  granular  kidney  is  undoubted.2  Lead 
and  alcohol  are  both  not  infrequent  factors  in  the  history  of  many 
cases  of  gout,  but  these  specific  relationships  will  be  subsequently 
discussed.  It  need  only  be  stated  here  that  there  are  no  specific 
aetiological  differences  traceable  in  the  morbid  anatomy  of  granu- 
lar kidney.  M.  Lancereaux 3  is  convinced  of  the  identity  of  the 
changes  in  the  kidneys  found  in  cases  of  ordinary  and  of  satur- 
nine gout.  He  has  described  a  variety  of  interstitial  nephritis 
due  to,  or  rather  consecutive  to,  alteration  in  the  arterial  system, 
associated  with  arthritis,  indistinguishable  from  the  chronic 
rheumatic  form  of  the  disorder.  He  therefore  believes  that  there 
are  at  least  two  forms  of  granular  kidney.  The  latter  variety 
is  that  now  recognized  as  a  part  of  the  constitutional  cachexia 
of  arterio-capillary  fibrosis,  which  I  am  disposed  to  believe  is,  in 
many  instances,  a  manifestation  of  gouty  inheritance. 

To  differentiate  the  two  varieties  described  by  Lancereaux,  it 
would  be  necessary  to  record  the  clinical  symptoms  of  the  arthritis 
more  in  detail,  and  to  examine  many  of  the  joints  in  a  larger 
number  of  cases  than  appears  to  have  been  done. 

The  term  "gouty"  has  been  used  synonymously  by  some  authors 
to  signify  "granular."  Todd  proposed,  in  1 846,  to  apply  this  term 
to  such  contracted  conditions  of  kidney  as  were  associated  with 
a  decided  gouty  diathesis.      He  gives  particulars  of  two  cases  of 

1  Berlin,  klin.  Wochenschrift,  No.  I,  1884. 

2  Dr.  Fenwick  found  deficiency  of  sulpho-cyanide  of  potassium  in  the  saliva  in 
cases  of  lead-poisoning.  This  is  the  reverse  of  the  condition  found  in  gouty  subjects. 
Op.  cit.,  p.  124. 

3  Vide  Lancereaux,  Trans.  Int.  Med.  Congress,  i88r    vol.  i. 


102  MORBID    ANATOMY    OF    GOUT. 

true  gout  in  which  streaks  of  lithate  of  soda  were  found  in  the 
tubes  of  the  cones  of  the  kidneys.1 

The  view  that  the  small  red  granular  kidney  is  peculiar  and 
due  to  gouty  affection  alone,  is  not  sustained  by  experience.  It 
is  true  that  in  this  form  the  deposits  of  uric  acid  and  urates 
are  commonly  found,  situated  either  amongst  the  granulations 
on  the  surface,  or  in  streaks  in  the  pyramids.  Other  forms  of 
granular  kidney  are,  however,  met  with  as  the  result  of  gouty 
influence,  and  hence  it  is  not  possible  to  pronounce  that  any 
particular  variety  of  cirrhosed  or  contracted  kidney  is  specifically 
significant  of  gouty  disease. 

Dr.  Dickinson  has  shown  that  kidneys  rendered  granular  by 
gout  commonly  advance  to  the  most  extreme  degree  of  the  disease, 
because,  from  the  enduring  nature  of  the  cause,  they  have  time 
to  develop  the  utmost  extent  of  granulation  compatible  with 
life.2 

Uric  acid,  yellowish  in  colour,  is  found  deposited  in  small  granu- 
lar or  crystalline  particles  in  the  cortical  and  pyramidal  portions 
of  the  kidneys.  They  are  commonly  scattered  in  the  cortex, 
but  in  linear  arrangement  in  the  medulla,  sometimes  thickly  set 
at,  and  encrusting,  as  it  were,  the  apices  of  the  papillae.  Micro- 
scopically, these  deposits  are  found  both  in  the  tubules  and  in  the 
iutertubular  stromal  tissue.  Uratic  salts  may  be  found  in  the 
same  situations.  The  existence  of  such  a  deposit,  even  in  granular 
kidneys,  is  not  by  itself  certain  evidence  of  gouty  disease,  and  we 
are  here  reminded  that  the  uric  acid  diathesis,  although  closely 
related  to,  is  not  the  same  condition  as,  the  gouty.3 

Uratic  depositions  are  found  in  the  pyramidal  tubular  system 
in  very  young  children,  but  never,  according  to  Klebs,  in  those 
whose  lungs  are  unexpanded,  and  hence  it  is  presumed  that 
digestion  has  begun,  and  has  been  carried  on  under  the  influences 
of  defective  respiration.4      Fagge   directed  attention  to  the  fact 

1  Clin.  Lect.  (xii.)  on  Certain  Diseases  of  the  Urinary  Organs,  1857. 

2  Op.  cit.,  p.  157. 

3  As  Sir  James  Paget  *  has  remarked,  "  Many  children  and  young  people,  whom 
you  cannot  reasonably  accuse  of  gout,  produce  large  excess  of  lithic  acid  in  the  urine  ; 
and  the  lithates  are  the  most  common  constituent  of  urinary  calculi  in  the  children  of 
the  poor,  among  whom  one  would  suppose  the  gouty  constitution  most  unlikely  to 
occur.  In  the  children  of  the  middle  and  upper  classes,  in  whom  the  inheritance  of 
the  lithic  acid  diathesis  may  be  expected,  calculus  of  any  kind  is  one  of  the  very 
rarest  of  diseases." 

4  Atlas  of  Illustrations  of  Pathology.  Resume  of  Renal  Pathology,  Prof.  Green- 
field, p.  12,  fasc.  ii.     New  Syd.  Soc,  1879. 

*  Op.  cit.,  p.  377.     Lond.,  1879. 


URATIC    DEPOSITS    IN    THE    KIDNEYS.  1 03 

that  uratic  deposits  in  the  kidney  are  commonly  met  with  in 
Germany,  where  gout  is  rare.  Castelnau,  Garrod,  Charcot,  and 
Dickinson  are  of  opinion  that  the  deposit  is  in  the  matrix,  but 
Garrod  allows  that  it  is  also  found  in  the  tubules. 

Cornil  and  Ranvier  state  that  urates  are  primarily  deposited  in 
cells,  which  are  the  centres  whence  the  free  crystals  spring,  and 
which  play  an  active  part  in  the  phenomena  of  simple  deposit.1 

According  to  Senator,  amorphous  uratic  deposit  is  first  found 
in  the  tubules  and  their  epithelium,  extending  later  into  the 
interstitial  tissue,  and  becoming  crystallized.  Greenfield  states 
that  these  deposits  are  commonly  found  in  the  connective  tissue 
of  the  cortex,  and  but  rarely  in  the  tubules. 

There  appears  to  be  a  common  belief,  especially  on  the  Conti- 
nent of  Europe,  that  the  contracted  kidney  of  gout  is  constantly 
associated  with,  if  not  somewhat  dependent  on,  uratic  deposit. 

My  own  experience  is  not  singular  in  this  country  in  indi- 
cating that  such  is  not  the  case.  These  deposits  are,  in  truth, 
somewhat  rarely  found  in  the  kidneys  of  the  gouty.  If  this 
statement  is  true  for  observations  made  in  England,  it  may  fairly 
over-ride  Continental  opinion  drawn  from  far  smaller  fields  of 
study. 

In  Dr.  Moore's  eighty  cases,  deposits  were  found  in  the  pyra- 
mids in  six  cases,  and  in  the  tubules  (specifically  mentioned)  in 
six  cases.  Hence,  in  hardly  one-seventh  of  these,  which  were  all 
instances  of  well-marked  uratic  arthritis,  did  tubal  or  interstitial 
deposits  occur.  As  remarked  by  Ebstein,  gout  can  only  be  the 
cause  of  calculous  disease  in  those  cases  in  which  intra-tubular 
deposits  occur.  In  many  cases,  however,  calculous  formation  is 
an  incomplete  phase  of  gout,  and  may  precede,  accompany,  or 
follow  articular  troubles.  Sydenham's  own  case  was  an  example 
in  point.  It  is  most  frequent  to  find  in  these  cases  that  the 
gravel-phase  has  preceded  the  articular  one.  With  onset  of 
interstitial  nephritis,  it  is  conceivable  that  intra-tubular  deposits 
may  be  subsequently  washed  out  by  the  free  secretion  of  urine 
under  high-pressure. 

A  distinction  has  been  made  between  cases  in  which  uric 
acid  is  found  free  as  gravel,  and  those  in  which  indiscriminate 
deposit  of  urates  is  found  here  as  in  other  textures.  Intra- 
tubular  deposit  of  uric  acid  is  held  to  signify  gravel.  Inier- 
tubular  infiltration  with  urates  is  considered  more  distinctly 
gouty.  Deposits  certainly  occur  in  both  situations.  They  are 
infrequent  in  the  secreting  tubules  of  the  cortex.      The  kidney 

1  In  calcification  infiltration  begins  in  the  ground-substance. 


104  MORBID  ANATOMY  OF  GOUT. 

furnishes  almost  the  solitary  example  of  a  highly  vascular  struc- 
ture in  which  deposit  is  met  with. 

The  morbid  anatomy  relates  to  all  the  component  tissues.  In 
a  well-marked  case,  the  organ  is  shrunken  and  more  or  less 
indurated.  Its  colour  is  red.  The  capsule  is  thickened  and 
adherent.  The  surface  is  rough  and  granulated,  and  small  cysts 
are  commonly  seen  on  it.  Some  of  the  granular  eminences  are 
yellowish  or  grey  in  colour,  and  are  as  large  as  mustard-seed. 
To  this  form  of  kidney  Bright  applied  the  term  "  contracted." 
Such  kidneys  are  not  always  small,  and  may  be  larger  than 
natural.  Small  kidneys  thus  affected  weigh  about  3  oz.  The 
granulations  are  surrounded  by  depressions,  and  in  stripping  off 
the  capsule  portions  of  them  may  come  away  with  it.1 

On  section  there  is  often  much  fat  in  the  pelvis.  The  pyramidal 
cones  are  not  distinctly  marked  off  from  the  cortex.  The  cortex 
is  much  wasted,  it  may  be  unevenly  ;  and  so,  in  parts,  the  pyramids 
may  almost  come  to  the  surface.  Numerous  small  cysts  may 
exist  in  it,  full  of  yellowish  gelatinous  fluid.  That  portion 
between  the  pyramids  is  less  apt  to  waste  than  the  superficial 
layer,  and  suffers  later  in  time  than  the  latter.  The  pyramids 
undergo  little  change,  but  may  waste  to  a  slight  extent. 

These  are  the  naked-eye  characters  of  the  so-called  "  small  red 
granular"  or  "gouty"  kidney.  But,  as  has  been  stated,  large 
and  mixed  granular  forms  may  be  found  dependent  on  gout, 
associated  with  some  degree  of  tubular  nephritis.  Large  vessels 
may  be  seen  in  the  cortex  with  rigid  walls.  The  arteries  are 
usually  hard,  atheromatous,  and  narrowed  in  calibre. 

The  essential  and  grossest  change  in  this  form  of  kidney  is 
the  chronic  inflammatory  sclerosis,  which  mainly  affects  the  inter- 
stitial matrix  or  supporting  tissue  of  the  organ.  A  round-celled 
granulation  tissue  is  formed,  which  proceeds  to  increased  forma- 
tion of  connective  tissue.  This  is  believed  by  Greenfield2  to 
begin  in  the  vessels  and  glomeruli  of  the  peripheral  portions  of 
the  interlobular  arteries.  These  become  thickened  in  their  intima 
and  sheaths,  while  fibro-ruuscular  hypertrophy  occurs  in  the 
middle  coat.  The  glomeruli  atrophy  in  parts,  and  their  associated 
tubules  likewise  waste,  owing  to  compression  from  the  fibroid 
transformation  of  the  connective  tissue.  This  leads  to  the  fibroid 
depressions  seen  on  the  surface,  which  are  sometimes  joined  by 

1  Adherent  capsules  are  not  always  met  with  in  kidneys  presenting  signs  of  inter- 
stitial overgrowth.  Sometimes  the  capsules  strip  off  fairly  well,  or  completely,  when 
microscopic  examination  reveals  a  good  deal  of  cirrhotic  change. 

2  Op.  cit. 


HISTOLOGY    OF    INTERSTITIAL    NEPHRITIS.  IO5 

newly-developed  vessels  from  the  capsule,  and  thus  rendered 
deep-red  by  contrast  with  the  paler  and  prominent  granulations. 
This  process  spreads  gradually  but  irregularly  throughout  the 
cortex.  New  development  of  connective  tissue  takes  the  place  of 
the  wasted  elements,  with  accumulated  leucocytes,  and  according 
to  the  extent  of  this  is  the  size  of  the  organ  in  any  particular 
instance.  This  sclerosing  process  is  not  uniform,  but  is  apt  to 
occur  in  certain  areas.  The  tubular  system  as  a  whole  escapes 
primary  disorder,  but  suffers  compression  secondarily  in  the 
affected  areas  from  intertubular  fibrosis,  which  may  also  lead  to 
the  formation  of  cysts.  These  are  now  believed  to  be  due  to 
distension  of  tubules  or  Malpighian  capsules,  resulting  from 
complete  obstruction  of  their  lumen.  The  glomeruli  become 
thickened,  and  their  vessels  dwindle  into  small  tufts.  Tracts 
are  found,  as  described  above,  iu  which  the  tubules  have  been 
destroyed  or  have  greatly  atrophied.  The  sclerosing  process 
causes  the  glomeruli  to  be  drawn  together  in  parts.  The  tubal 
epithelium  is  apt  to  accumulate  and  distend  the  tubes  in  places, 
and  is  often  fatty.1 

The  vascular  changes  are  primarily  those  of  endarteritis  obli- 
terans in  the  larger  arteries.  The  capillaries  are  destroyed  with 
the  tubules  by  compression. 

In  treating  of  the  morbid  anatomy  of  gout,  the  changes  in  the 
cardio-vascular  system  associated  with  the  condition  of  the  kidneys 
cannot  be  studied  apart  from  the  latter.  These  are  the  concomi- 
tants of  interstitial  nephritis,  however  induced.  They  consist 
essentially  of  hypertrophy  of  the  left  ventricle  and  the  arterial 
tunics.  The  mechanism  of  these  changes  has  been  a  much-debated 
subject.  The  most  acceptable  doctrine  refers  the  cardiac  hyper- 
trophy to  thickening  and  contraction  of  the  arterial  tunics  as  well 
in  the  kidneys  as  in  the  system  at  large,  leading  to  high  arterial 
tension  throughout  the  body.  The  changes  in  the  arteries  are 
proved  by  microscopical  examination,  the  high  tension  is  ascer- 
tained by  the  finger  or  the  sphygmograph,  and  both  progress 
steadily  with  the  progress  of  the  chronic  nephritis.  The  ventricular 
hypertrophy  is  entailed  by  excess  of  work  in  forcing  the  blood 
through  obstructed  vessels.  It  is  certain  that  obstruction  in  the 
arterioles  can  produce  high  arterial  tension,  and  this  may  suffice 
to  induce  ventricular  hypertrophy.  But  in  chronic  sclerosing 
nephritis  there  is  probably  an  additional  source  of  obstruction 
due  to  laborious  circulation,  in  the  capillaries,  of  blood,  which  is 

1  For  man}'  points  in  the  foregoing  description  I  am  under  obligation  to  the  able 
resume  by  Professor  Greenfield  already  referred  to. 


106  MORBID  ANATOMY  OF  GOUT. 

rendered  impure  by  defective  renal  function.  Some  of  these 
impurities  are  believed  to  stimulate  directly  the  muscular  walls  of 
the  heart  and  arteries,  and  so  to  lead  to  hypertrophy.  It  thus 
appears  that  the  renal  lesion  is  sufficient  to  account  for  the 
associated  cardio-vascular  changes. 

The  views  of  Gull  and  Sutton  respecting  the  systemic  degene- 
ration termed  by  them  "  arterio- capillary  fibrosis,"  are  not,  in  my 
opinion,  displaced  by  the  explanation  just  given.  This  disorder 
is  conceived  to  be  widespread,  and  the  kidneys  but  take  a  part 
in  it.  The  series  of  changes  already  described  cannot  be  contro- 
verted. They  will  probably  retain  their  place  in  pathology,  and 
Dr.  George  Johnson's  name  will  ever  be  honourably  associated  as 
the  earliest  interpreter  of  them.  I  believe  in  the  existence  of  a 
systemic  arterio -capillary  fibrosis  as  a  definite  tissue-lesion,  and 
some  of  the  forms  of  granular  kidney  are  setiologically  related  to 
it.  How  far  gouty  disease  takes  part,  if  at  all,  in  it,  I  am  not 
now  prepared  to  state  ;  but  such  a  view  deserves  consideration 
in  determining  the  outcome  and  transformations  of  the  gouty 
habit  as  modified  by  inheritance,  and  by  other  conditions. 

Dr.  Mahomed  described  a  form  of  chronic  Bright's  disease 
without  albuminuria,  the  kidneys  being  red  and  granular,  and  the 
changes  being  chiefly  vascular,  including  thickened  arteries, 
glomeruli,  and  fibro-hyaline  intertubular  thickening.  Cardio- 
vascular changes  with  high  arterial  pressure  were  present.  He 
collected  sixty-one  cases.  Of  these,  six  were  associated  with 
gout  and  accompanied  with  great  cardiac  hypertrophy,  high  arte- 
rial tension,  and  non-albuminous  urine.1 

Lardaceous  disease  is  very  rarely  associated  with  the  nephritis 
due  to  gout,  perhaps  hardly  in  two  per  cent,  of  all  cases.  The 
inhibitory  effect  of  gout  on  struma  may  perhaps  account  for  this. 


Changes  in  the  Heart,  Arteries,  and  Veins. 

The  condition  of  the  heart  varies  according  to  the  stage  of 
gouty  disease  present  when  death  occurs.  Degeneration  is  most 
frequent  in  the  later  periods,  when  gouty  cachexia  has  super- 
vened. The  changes  relate  to  the  pericardium,  muscular  walls, 
valves,  and  great  vessels. 

The  Pericardium It  is  difficult  to  determine  the  direct  rela- 
tion, if  such  exist,  between  gouty  and  ordinary  pericarditis  in 
the  subjects  of  interstitial  nephritis,  in  whom  alone  it  practically 

i  Trans.  Int.  Med.  Congress,  1881,  vol.  i. 


PERICARDITIS.       CONDITION   OF    CARDIAC    WALLS.       IOJ 

occurs.  James  Begbie  recorded  the  case  of  a  lady,  aet.  twenty- 
seven,  who  was  gouty,  and  came  of  gouty  family,  who  died  of 
pericarditis,  and  he  stated  that  he  had  known  at  least  two  other 
instances.1      I  have  not  met  with  an  example. 

In  the  cachexia  of  gout  with  granular  kidneys,  pericarditis 
may  occur  not  infrequently,  and  is  usually  fatal.  In  sixteen  of 
sixty-eight  cases  of  granular  kidneys  from  all  causes,  Dr.  Dick- 
inson met  with  recent  pericarditis,  and  if  false  membrane  and 
adhesions  had  been  reckoned  in,  the  number  would  have  been 
far  larger.  Dr.  Norman  Moore  found  signs  of  pericarditis —  effu- 
sion, lymph,  and  adhesions — in  twelve  out  of  eighty  cases  of  true 
gout,  in  all  associated  with  granular  kidney.  Garrod  found  uric 
acid  in  pericardial  effusion  in  gout. 

Cardiac  Walls. — Hypertrophy  of  the  left  ventricle  figures  as  the 
leading  change  here.  It  is  practically  almost  always  present  in 
greater  or  less  degree,  as  associated  with  the  renal  changes  already 
described.  Rarely,  no  hypertrophy  is  found,  but,  instead,  fatty 
degeneration  and  dilatation.  The  measure  of  hypertrophy  is  regu- 
lated by  the  general  nutritional  state  of  the  individual,  and  by  the 
amount  of  involvement  of  the  kidneys  and  arterio-capillary  vessels 
in  the  general  sclerosis  which  prevails.  The  nutrition  of  the  cardiac 
walls  is  in  relation  to  the  presence  or  absence  of  pericardial  ad- 
hesions, which  may  lead  to  myocarditis,  softening,  or  fibroid  change, 
and  to  the  permeability  of  the  coronary  arteries,  which  is  often 
diminished  by  endarteritis  or  by  atheromatous  and  calcific  deposits. 
Changes  in  the  other  cavities  depend  on  the  competence  of  the 
left  ventricle  as  secured  by  its  nutrition,  or  as  affected  by  co- 
existing valvular  defects,  and  on  the  presence  or  absence  of 
bronchitis  and  emphysema.  The  apex  is  often  formed  entirely 
by  the  left  ventricle,  the  right  appearing  very  small  beside  it. 
There  is  commonly  associated  dilatation  of  the  left  side.  Fatty 
degeneration  may  ensue  on  profound  atheroma  of  the  coronary 
arteries.  The  weight  of  the  heart  is  usually  greatly  increased. 
The  average  weight  in  forty-nine  cases  examined  by  Dr.  Norman 
Moore  was  i6|  oz.  In  some  the  weight  was  over  20  oz.,  and 
in  one  reached  26  oz.  (The  natural  weight  is  1 1  oz.  for  the 
male,  and  9  oz.  for  the  female.)  Softening  or  partial  fatty 
change  is  more  commonly  seen.  Ebstein  believes  that  the  heart 
is  imperfectly  nourished  by  blood  rich  in  urates.  He  found 
uratic  nodules  in  the  heart's  muscle  in  one  case,  some  as  large 
as  a  hemp-seed,  and  many  smaller  ones.  In  the  vicinity  of  these 
were  small-celled  infiltrations,  necrosing  changes  due  to  action 
1  Op.  cit.     Edinburgh,  1862. 


108  MORBID  ANATOMY  OF  GOUT. 

of  uric  acid.      No  other  observer  has  met  with  cardiac  deposits 
of  urates. 

Endocarditis This  is  practically  unknown  in  an  acute  form 

as  a  gouty  lesion.1  The  changes  affecting  the  endocardium  are 
confined  to  chronic  sclerosing  lesions  of  the  valves,  and  mainly  . 
of  the  mitral  and  aortic  curtains.  Thickening  of  the  chordae,  with 
shortening,  atheromatous  patches,  and  calcareous  nodules  are 
found  as  the  result.  The  tricuspid  valve  is  rarely  involved,  and 
the  pulmonary  cusps  most  rarely.  In  the  only  case  of  the  latter 
known  to  me,  and  reported  to  the  Clinical  Society,2  there  was 
reason  to  believe  that  some  congenital  affection  of  the  valve  had 
occurred,  so  that  one  cusp  had  disappeared,  and  an  aneurysmal 
pouch  had  formed  below  its  proper  site.  This  was  in  a  gouty 
man.  Ebstein,  on  the  strength  of  uratic  infiltration  having  been 
met  with  on  the  valves,  conceives  that  gouty  endocarditis  may 
exist.  But  he  gives  no  facts  in  support  of  his  view,  and  there 
are  none  known  to  me.  The  fact  is,  that  uric  acid  is  only  found 
in  very  small  quantities  in  this  situation,  and  merely  impregnating 
the  ordinary  calcareous  salts  met  with  in  ordinary  cases  of  the 
kind. 

That  the  sclerosing  changes  are  really  due  to  gouty  influence, 
and  not  to  associated  alcoholic  habit,  is  proved  by  their  occurrence 
in  strictly  temperate  gouty  individuals.  Dr.  Norman  Moore  re- 
marks that  "it  is  common  to  find  uratic  deposit  in  the  joints 
of  those  persons  whose  aortic  valves  show  chronic  degenerative 
changes,  with  calcification,  and  who  therefore  belong  to  the  class 
of  patients  likely  to  have  had  angina  pectoris." 

Aorta,  Arteries,  and  Capillaries. — Dilatation  of  the  aorta,  with 
loss  of  elasticity,  and  atheroma  in  varying  amount,  even  to  calcific 
change,  are  met  with. 

Smaller  arteries  gape  on  section,  and  show  thickened  walls  in 
most  places.  These  changes  are  especially  well  seen  in  the  cere- 
bral vessels,  and  hence,  under  the  influence  of  the  powerful  left 
ventricle,  are  prone  to  rupture,  and  induce  a  very  common  ending 
to  all  such  cases,  viz.,  apoplexy.  As  has  been  pointed  out  by 
Sir  William  Jenner,  such  vessels  are  not  always  brittle.  They 
may  be  classed,  indeed,  under  two  heads — those  that  toughen,  and 
those  that  become  brittle.  This  is  probably  dependent  on  tex- 
tural  peculiarity  of  the  individual.  In  respect  of  tendency  to 
rupture,  it  has  been  noted  by  my  late  colleague,  Dr.  Southey, 

1  Sibson  observed  one  case  in  which  pericarditis  and  endocarditis  occurred  in  a 
man  with  saturnine  gout.  The  condition  of  the  urine  is  not  recorded.  Works,  edited 
by  Dr.  Ord,  vol.  iv.  2  Trans.  Clin.  Soc,  vol.  xxi.  p.  18,  1 888. 


AORTA,    ARTERIES,    CAPILLARIES.       VEINS.  IC9 

that  apoplexy  does  not  usually  occur  until  the  left  ventricular 
wall  has  begun  to  soften  and  decay. 

Respecting  the  relationship  between  gout  and  cerebral  haemor- 
rhage, it  is  shown  by  Dr.  Norman  Moore  that  in  thirty-two  cases 
of  the  latter  in  males,  uratic  deposits  were  present  in  thirteen 
instances,  or  in  somewhat  less  than  one-third  of  the  cases.  The 
earliest  age  in  which  these  were  associated  was  twenty- eight,  and 
the  oldest  sixty-six  years. 

In  ten  fatal  cases  of  gout,  Pye-Smith  found  two  resulting 
from  cerebral  hemorrhage. 

Murchison  noted  that  arterial  atheroma  supervening  early  in 
life,  and  diseases  of  the  aortic  valves,  which  are  not  congenital, 
and  are  independent  of  rheumatism  and  injury,  are  met  with 
chiefly  in  the  subjects  of  the  lithic  acid  dyscrasia  or  of  gout. 

Sections  of  small  arteries  show  great  thickening  of  the  in- 
ternal longitudinal  and  external  circular  muse  alar  coats,  and  the 
outer  fibrous  coat  is  also  thickened.  With  respect  to  this  endar- 
teritis, although  it  is  commonly  associated  with  granular  kid- 
neys of  all  varieties,  it  must  be  affirmed  that  it  is  of  especial 
frequence  in  persons  of  arthritic  habit,  and  thus  occurs  very 
markedly  in  certain  families. 

Aneurysm  is  rare  in  the  gouty,1  and  so,  too,  is  gangrene  from 
arterial  embolism  and  thrombosis.  Deposits  of  urates  have  been 
found  in  the  renal  arteries  by  Dr.  Moore.  He  affirms  that  "  urates 
are  present  in  the  joints  of  a  large  proportion  of  those  persons 
over  forty  years  of  age  who  die  of  cerebral  haemorrhage. " 

The  changes  in  the  capillaries  relate  to  thickening  and  brittle- 
ness,  whence  haemorrhages  and  ecchymoses  in  various  parts,  as 
in  the  bladder,  nasal  mucous  membrane,  and  the  conjunctivas. 

Veins. — Morbid  anatomy  tells  little  in  respect  to  these.  Clini- 
cal observation  tells  more.  The  venous  troubles  of  the  gouty, 
though  serious,  happily  most  often  end  favourably.  Phlebitis  is 
well-recognized  as  a  gouty  ailment,  with  thrombosis,  and  the  clots 
may  be  dislodged  and  cause  sudden  death  by  impaction  in  the 
heart,  pulmonary  artery,  and  lungs.2  Schroeder  van  der  Kolk 
has  recorded  a  case  in  which  the  walls  and  valves  of  the  veins 
were  thickly  infiltrated  with  urate  of  lime.  The  veins  are  apt 
to  be  large  and  full  in  gouty  persons  of  sanguine  type,  and  varix 
is  not  uncommon  in  them.  Large  veins  may  become  suddenly 
and  spontaneously  blocked,  sometimes  permanently  so,  as  in  the 

1  In  N.  Moore's  tables  is  a  case  in  which  an  aneurysm,  the  size  of  a  walnut,  burst 
into  the  pericardium.  The  vessels  were  generally  atheromatous.  Man,  aet.  44. 
Kidneys  granukr  and  cystic.  2  Nederland  Lancet,  1853. 


IIO  MORBID    ANATOMY    OF    GOUT. 

axillary  and  iliac  veins.  The  superficial  crural  veins  are  perhaps 
the  most  frequent  sites  for  this,  and  the  thrombosis  may  be 
patchy,  extending  up  or  down  the  limb.  At  times,  great  pain 
accompanies  this  process,  of  which  I  have  seen  one  well-marked 
instance  ;  more  often  only  a  little  aching  and  uneasiness  is  felt. 
The  veins  are  felt  like  cords,  and  oedema  occurs,  or  not,  accord- 
ing to  the  degree  of  mechanical  impediment.  Such  cases  are 
very  tedious,  and  recurrence  is  common.1  The  occurrence  of 
phlebitis  in  an  elderly  person  without  any  evident  external  cause, 
according  to  Paget,  warrants  suspicion  of  gout,  and  this  is'  per- 
haps the  most  common  form  of  idiopathic  phlebitis. 

The  frequency  of  haemorrhoids  has  been  already  alluded  to. 

Liver. — The  morbid  anatomy  of  the  liver  in  gout  should  surely 
demand  attention,  since  few  organs  in  the  body  have  been  more 
believed  to  be  in  fault  in  this  malady.  In  truth,  there  is  but 
little  to  be  told  concerning  the  liver  in  those  dying  directly  from 
gouty  cachexia. 

Many  of  the  changes  are  doubtless  due  to  associated  heart- 
disease.  Chronic  congestion,  induced  by  alcoholic  indulgence  or 
over-eating,  may  lead  to  the  capsular  thickening  sometimes  met 
with.  Pseudo-cirrhosis  is  due  to  venous  remora  resulting  from 
cardiac  obstruction  in  many  cases.  Fatty  degeneration  is  not 
uncommon  in  cases  of  gouty  cachexia,  and  the  liver  may  thus  be 
much  enlarged  in  volume.  The  organ  has  been  found  small  with 
thickened  capsule,  which  may  be  adherent  to  adjacent  parts. 

Whether  true  cirrhosis  can  be  induced  by  the  gouty  habit, 
apart  from  other  and  more  common  causes,  is  still  a  vexed  ques- 
tion in  pathology.  My  own  opinion  is  that  this  may  occur,  but 
it  is  not  easy  to  furnish  absolute  proof  of  it.  Murchison 2  noted 
the  frequency  of  cirrhosis  in  connection  with  gout,  and  remarked 
that  ' '  the  condition  of  liver  which  develops  gout  renders  it  liable 
to  suffer  from  alcohol,  even  in  small  quantity."  He  refers  to 
cases  of  cirrhosis  which  have  been  preceded  for  years  by  lithic 
acid  dyscrasia  and  dyspepsia,  in  which  alcohol  bears  no  part, 
and  which  have  been  termed  chronic  gouty  hepatitis.  Trousseau 
alludes  to  such  cases.3  Murchison  reported  the  case  of  a  girl, 
get.  twelve  years,  who  suffered  from  interstitial  hepatitis  as  the 
result  of  a  chill  which  ended  in  cirrhosis.  Both  parents  were 
gouty.4      It  is,  at  any  rate,  certain  that  all  cases  of  cirrhosis  are 

1  Vide  Prescott  Hewett,  Clin.  Soc.  Trans.,  vol.  vi.,  1873.  Paget,  op.  clt.,  p.  376, 
and  St.  Barth.  Hosp.  Reports,  vol.  ii.  p.  82,  1866.  Tuckwell,  St.  Barth.  Hosp. 
Reports,  vol.  x.  p.  23.  "  Lect.  on  Dis.  of  Liver,  2nd  edit.,  p.  283,  1877. 

3  Clin.  Med.,  vol.  iv.  p.  381.  4  Op.  cit.,  Appendix,  p.  631. 


CIRRHOSIS    OF    THE    LIVER.       BILIARY    CALCULI.         Ill 

not  due  to  alcoholic  influence.  Various  irritants  may  excite  it. 
It  may  occur  in  animals.  Dr.  Norman  Moore's  tables  show  that 
in  the  majority  of  cases  of  cirrhosis  of  the  liver,  uratic  deposit  is 
not  to  be  found  in  the  joints.  In  twenty-three  cases,  in  both 
sexes,  he  found  urates  in  the  joints  in  but  three  instances  in 
men,  aged  forty-one,  forty-three,  and  sixty  years.  Ebstein  has 
recorded  cases  of  hypertrophic  cirrhosis  in  gouty  men  without 
portal  venous  obstruction. 

Degenerative  joint-changes  are  sometimes  met  with  in  cases 
of  cirrhosis  of  the  liver.  Erosion  of  cartilages,  eburnation  of 
bone,  and  outgrowths  (lipping)  may  occur  without  iiratic  deposit. 
Alcoholic  intemperance  is  presumable  for  most,  if  not  all,  of 
these  cases.  The  special  significance  of  this  association  of  joint- 
change  with  cirrhosis  of  the  liver  would  appear  to  be  that  more 
widely  spread  lesions,  indicative  of  degeneration,  are  to  be  found 
than  is  commonly  believed  in  chronic  alcoholism.  These  changes 
only  afford  a  parallel  to  the  articular  manifestations  of  gout  in 
respect  of  their  far-reaching  character,  and  their  determination 
to  joints.  Uric  acid  disturbances  do  not  prevail  in  such  cases,  as 
a  rule,  because  they  are  not  gouty. 

Biliary  Calculi Biliary  calculi  are  not  often  found  in  the  bodies 

of  those  whose  tissues  show  manifest  signs  of  gout.  In  Dr. 
Moore's  eighty  cases,  calculi  were  only  found  in  three  instances, 
twice  in  men  aged  fifty-four  and  sixty-two  years,  and  once  in  a 
woman  aged  fifty.  In  the  families  of  gouty  persons,  and  especi- 
ally in  women,  there  is,  however,  not  infrequently  clinical  history 
of  biliary  colic.  Biliary  and  renal  calculi  have  long  been  known 
to  co-exist.  I  am  inclined  to  regard  the  occurrence  of  biliary 
calculi  as  one  of  the  occasional  manifestations  in  women  of  im- 
perfectly developed  gouty  habit.  Uric  acid  is  stated  by  Charcot 
to  have  been  found  in  the  gall-bladder  in  the  form  of  calculi. 
This  is  on  the  authority  of  Frerichs.  A  reference  to  the  original 
observation,  however,  shows  that  this  was  very  doubtful.  The 
source  of  the  calculus  examined  was  not  certainly  determined,  and 
it  was  probably  of  renal  origin.  I  have  no  knowledge  of  any 
example  of  the  kind. 

It  is  certain  that,  in  many  cases  in  which  gall-stones  exist, 
there  is  family  history  of  ailments  of  a  gouty  nature,  as  well  as 
of  true  gout,  asthma,  migraine,  neuralgia,  lithiasis,  and  ten- 
dency to  urticaria.  The  habits  of  life  leading  to  gall-stones  are 
such  as  induce  gout, — to  wit,  high  living,  anxiety,  mental  tension, 
and  sedentary  pursuits. 

It  has  been  shown  that  biliary  colic  is  somewhat  rare  after 


I  I  2  MOEBID  ANATOMY  OF  GOUT. 

the  age  of  fifty,  while  the  formation  of  calculi  in  the  gall-bladder 
tends  to  go  on  without  dislodgment  with  advancing  years,  and 
they  are  often  found  in  bodies  where  their  presence  has  been 
unsuspected  during  life.  They  are  seldom  found  in  associa- 
tion with  cirrhosis  of  the  liver  induced  by  spirit-drinking,  and 
are  more  common  in  persons  who  are  intemperate  in  malt  liquor, 
which  is  notoriously  gout-inducing. 

In  hot  climates  they  are  not  common,  and  the  same  holds 
good  for  gout.  Persons  leading  active,  open-air  lives  are,  as  a 
rule,  exempt  from  gout,  lithiasis,  aud  biliary  calculi. 

The  opinion,  therefore,  as  to  the  significance  of  gall-stones  as 
a  gouty  indication  in  any  individual  is,  like  many  others  in 
respect  of  this  disorder,  formed  upon  clinical  rather  than  upon 
post-mortem  data. 

I  would  just  note  in  this  connection  the  occasional  occurrence 
of  cancer  of  the  gall-bladder  and  ducts,  induced  by  irritation  of 
calculi,  which  is  met  with  in  gouty  persons,  especially  in  women. 

Genito-Urinary  System. 

Bladder. — Cystitis  is  plainly  a  gouty  trouble  in  certain  cases, 
and  may  occur  in  persons  who,  though  gouty,  have  never  had 
regular  gout.  Todd  described  examples,  and  regarded  them  as 
analogous  to  gouty  pneumonia,  bronchitis,  or  gastritis.  It  may 
occur  by  sharp  metastasis.  It  is  more  common  in  elderly  per- 
sons, and  in  those  with  prostatic  enlargement.  The  muscular  coat 
appears  to  be  sometimes  alone  involved. 

The  possibility  of  calculous  cystitis  must  be  borne  in  mind  in 
these  cases. 

Urethra. — Urethritis  of  gouty  origin  is  distinctly  recognized 
and  is  apt  to  supervene  at  the  end  of  an  articular  attack  when 
the  pain  is  passing  away,1  or  may  occur  spontaneously,  or  be 
excited  by  pure  connection.  Fibroid  thickening  of  the  spongy  and 
prostatic  portions,  leading  to  tough  stricture,  may  be  found. 
Thrombosis  of  the  veins  in  the  corpus  cavernosum  of  the  penis 
is  not  very  rare,  leading  to  painless  nodules,  hard  and  circum- 
scribed, varying  in  size  from  a  pea  to  that  of  a  French  bean. 
These  disappear  very  slowly,  sometimes  not  completely. 

Indurations  of  the  fibrous   sheath  of  the  corpus  cavernosum, 

caused  by  fibroid  tissue  in  bands  or  lumps,  may  occur  on  the 

sides,   dorsum,   or  septum.      These  induce  chordee   on    erection. 

1  Essai  sur  V  Urethrite  gouttcuse.     Thdse  pour  le  Doctora'.     E.  G.  Turbure.     Paris, 


PROSTATE  GLAND.      TESTIS.       UTERUS  AND  OVARIES.       I  I  3 

They  are  usually  very  chronic,  and  perhaps  may  not  disappear 
entirely. 

Prostate  Gland — Any  post-mortem  changes  detectible  here  will 
be  results  of  long-continued  irritation  from  calculi  or  from  enlarge- 
ment of  the  gland.  Paroxysmal  prostatic  gout  is  sometimes  met 
with,  and  temporary  hardness  and  great  tenderness  of  the  part  are 
found  on  examination  by  the  rectum.1  Sacculation  of  the  bladder 
may  be  caused  as  the  result  of  the  more  permanent  enlargement, 
and  chronic  cystitis,  with  hypertrophy  of  the  muscular  and  con- 
gestion of  the  mucous  coats,  may  be  met  with. 

Testis Although  gouty  orchitis  occurs,  nothing  is  known  of 

its  morbid  anatomy.  Chronic  induration,  generally  of  the  body 
of  the  organ  and  not  of  the  epididymis,  may,  however,  result 
from  acute  gouty  orchitis.  The  testis  is  less  nodular  and  hard 
than  in  other  forms  of  this  disorder.  Dr.  Debout  D'Estrees  has 
recorded  cases.2  In  one  of  these  the  body  and  epididymis  were 
both  involved,  the  testis  being  thrice  its  natural  size.  No  effusion 
occurred  into  the  tunica  vaginalis.  The  latter  may,  however,  be 
met  with.  The  left  testis  is  that  commonly  affected.  Ebstein 
has  recorded  a  case  of  hydrocele  and  orchitis  on  the  left  side  in 
a  bed-ridden  gouty  man. 

Uterus  and  Ovaries — r Cases  of  uterine  gout  have  been  de- 
scribed. Sir  James  Simpson  reported  several.3  The  uterus  may 
be  affected  naetastatically  from  articular  gout,  and  has  been  found 
large  and  fixed  as  by  perimetritis.  Tumefactions  may  occur  in 
the  broad  ligaments.  The  mucous  membrane  has  not  been  found 
inflamed,  nor  the  cervix,  in  these  cases.  Menorrhagia  and 
dysmenorrhcea  are  certainly  sometimes  due  to  gouty  influences. 
As  against  these  assertions,  I  may  quote  the  opinion  of  my  col- 
league, Dr.  Matthews  Duncan,  who  tells  me  he  knows  of  no  facts, 
either  during  life  or  post-mortem,  that  warrant  the  term.  "  gouty  " 
affections  of  either  womb  or  ovaries,  and  that  he  knows  of  no 
gynaecologist  who  now  asserts  such  an  opinion.  He  remarks : 
' '  That  gout  may  affect  every  organ  and  tissue  1  do  not  deny.  I 
remember  well  having  the  same  opinion,  or  knowledge,  when  I 
saw  Simpson's  so-called  cases  in  Edinburgh,  and  when  I  was 
more  credulous  than  now." 

It  is  possible,  however,  that  the  influences  of  gouty  heredity 
are  not  recognized  in  many  cases  of  diseases  of  women,  simply 
because  no  overt  gouty  symptoms  present  themselves. 

1  "  I  have  certainly  seen  gout  in  the  urethra  and  prostate  gland." — Sir  H.  Halford, 
op.  cit.,  p.  108.  2  Loc.  jam  cit.,  p.  220. 

'■'  James  Begbie,  op.  cit.,  p.  19. 

H 


114  MORBID  ANATOMY  OF  GOUT. 

The  disorders  of  the  uterus  and  ovaries  which  depend  on  gouty- 
influence  have  no  recognized  morbid  anatomy,  because  they  do 
not  destroy  life.  Their  true  character  is,  therefore,  only  to  be 
determined  clinically,  and,  for  this  purpose,  regard  must  be  had 
to  the  general,  and  not  merely  to  the  local,  conditions  present  in 
any  given  case. 

I  shall  return  to  this  subject  in  a  future  chapter. 


CHAPTER  V. 

HEMATOLOGY  OF  GOUT. 

In  discussing  the  humoral  pathogeny  of  gout,  I  have  already 
entered  at  some  length  into  the  question  of  the  morbid  state  of 
the  blood.  Repeated  research  has  confirmed  most  of  what  has 
been  set  forth  by  Sir  Alfred  Garrod,  and,  in  truth,  there  is  little 
to  add  to  the  fruits  of  his  labours.  Not  many  physicians  are  so 
qualified  as  he  is  to  throw  light  on  this  subject,  which  demands 
the  knowledge  and  practical  skill  of  a  physiological  chemist.  He 
has  shown  that  the  blood  in  gout  is  invariably  rich  in  uric  acid, 
and  is  specially  charged  with  it  prior  to  and  during  attacks. 
During  recovery  from  acute  attacks,  diminution  of  uric  acid 
occurs.  In  the  intervals  between  earlier  attacks  no  appreciable 
increase  is  detectible  ;  but  in  chronic  gout,  at  all  times,  even  in 
inter-paroxysmal  periods,  excess  of  uric  acid  exists. 

The  amount  of  uric  acid  in  healthy  blood  is  so  small  as  practi- 
cally to  elude  detection.  In  gout,  Garrod  has  found  as  much 
as  0.175  parts  in  10.000.  His  "  thread-test"  has  been  repeat- 
edly practised  with  the  blood  of  the  gouty,  and,  when  carried  out 
with  exactness,  seldom  fails  to  indicate  presence  of  uric  acid  (as 
uratic  salts)  in  the  blood.  Better  results  are  obtained  from  blood- 
serum  procured  from  blood  directly  than  from  blister-serum,  and 
the  probable  explanation  of  this  is,  as  Garrod  suggests,  that  the 
inflammatory  process  induced  by  vesication  is  apt  to  destroy  the 
excess  of  uric  acid  in  the  part  thus  influenced.  It  is  best  to 
withdraw  about  one  or  two  ounces  of  blood  from  a  brachial  vein 
in  order  to  practise  this  method,  and,  as  pointed  out  by  Garrod, 
care  must  be  taken  to  employ  acetic  acid  of  proper  strength, 
that  of  the  British  Pharmacopoeia,  with  sp.  gr.  of  1.044,  of  which 
I OO  parts  by  weight  contain  3  3  parts  of  real  acetic  acid,  being 
most  suitable.1      Failure  to  find  evidence  of  uric  acid  may  arise 

1  Vide  Garrod'a  method,  described  at  length  in  his  book,  2nd  edit.,  p.  86. 


I  I  6  HEMATOLOGY    OF    GOUT. 

from  decomposition  of  the  serum,  due  most  frequently  to  high 
temperature,  in  which  case  the  uric  acid  is  changed  into  oxalic 
and  carbonic  acids. 

If  blister-serum  is  used,  it  should  not  be  taken  from  a  goutily 
inflamed  part. 

My  own  observations  confirm  Garrod's  facts.  It  may  be  con- 
fidently affirmed  that  in  the  blood  of  most  gouty  persons  there  is 
excess  of  uric  acid.  This  fact  has  been  noted  in  the  blood  in  both 
acute  and  chronic  gout,  but  more  markedly  in  the  former,  and 
not  only  is  this  true  during  active  phases  of  the  disease,  but  also 
in  the  intervals  between  acute  attacks  when  the  general  health  is 
good. 

Urichaemia,  however,  is  not  peculiar  to  the  gouty  state  alone, 
neither  is  it  always  demonstrable  in  cases  of  unequivocal  uratic 
arthritis.  It  is  present  in  leuchaemia,  chlorosis,  lead-poisoning, 
and  other  morbid  states,  which  have  no  marked  alliance  with 
gout.  Hence,  mere  urichsemia  is  not  an  absolute  sign  of  gout, 
and  does  not  by  itself  entail  a  paroxysm  of  it,  though  it  is  most 
often  present,  and  it  may  determine  incomplete  phases  of  gout. 

Diminished  alkalinity  of  the  blood  is  assumed  as  a  pathogenic 
factor,  depending  on  presence  of  uratic  salts.  Garrod  affirms 
that  the  reaction  of  the  blood  in  chronic  gout  is  more  nearly 
neutral  than  in  any  cases  but  the  stage  of  cholera-collapse  and 
some  forms  of  albuminuria. 

In  gouty  subjects  uric  acid  is  believed  to  be  often  retained  in 
the  liver  and  spleen.  Dr.  Haig's  researches  indicate  that  after 
five  grains  have  been  thus  stored  it  is  difficult  to  cause,  by  drug- 
or  other  interference,  any  further  retention. 

Blood-Plasma— Corpuscles. — Corpuscular  richness  is  not  affected 
in  gout,  the  red  globules  being  in  full  number.  The  leucocytes 
are  not  increased.1  Impoverishment  of  blood  is  not  usual  after 
paroxysmal  gout,  at  all  events  in  the  earlier  attacks,  and  in  this 
respect  there  is  a  marked  difference  from  rheumatic  fever.2 
Anaemia  occurs  as  part  of  the  cachexia  of  gout,  and  may  be  con- 
siderable after  haemorrhages  by  epistaxis  and  from  haemorrhoids. 
It  is,  however,  rapidly  recovered  from  in  the  gouty,  as  in  the 
subjects  of  haemophilia,  if  the  flux  be  arrested.  In  two  cases  of 
chronic  gout  under  my  care,  Dr.  Tylden  found  the  haemoglobin 
in  about  normal,  or  in  very  slightly  lessened,  proportion.  Where 
the  kidneys  are  already  affected  with  chronic  nephritis,  there  is 

1  Dr.  Tylden  made  several  examinations  for  me. 

2  The  red  globules  are  diminished  in  acute  gout,  according  to  Quinquand.      Vide 
Coupland's  Gulstonian  Lectures,  Lancet,  March  26,  1881. 


BLOOD.      FIBRIN.      ALBUMIiN.       UREA.      OXALIC   ACID.        I  1 7 

diminution  of  red  corpuscles  and  some  increase  of  leucoc;. 
This  is  in  relation  to  the  co-existence  of  albuminuria,  and  may 
hardly  be  reckoned  as  a  specifically  gouty  change.  In  granular 
kidney-disease,  the  red  globules  may  be  reduced  to  nearly  one 
half  the  normal,  and  the  leucocytes  may  be  increased  to  thrice 
the  average  number,  as  pointed  out  by  Dickinson.  In  saturnine 
gout,  there  is  commonly  marked  ameniia  or  spaneemia,  but  in  this 
case  there  is  direct  influence  of  a  special  blood-poison  on  the  red 
globules.  This  degree  of  anasmia  is  rarely  reached,  even  in  cases 
of  gouty  cachexia,  unless  there  has  been  poor  living  or  alcoholic 
intemperance. 

Fibrin. — Hyperinosis  may  fairly  be  assumed  in  certain  phases 
of  gouty  habit,  and  is  manifested  especially  by  tendency  to 
venous  thrombosis,  which  is  commonly  associated  with  phlebitis.1 
This  is  now  recognized  as  an  incomplete  form  of  gout.  No  exact 
researches  have,  however,  been  made.  Blood  drawn  from  a  gouty 
patient  appears  to  differ  in  no  way  from  that  taken  from  the 
subjects  of  indifferent  inflammatory  processes,  and  the  amount  of 
fibrin  is  probably  in  relation  to  the  degree  of  inflammation  present 
in  each  case,  being  increased  in  acute  inflammation. 

Albumen — Little  is  known  respecting  the  albumen  in  the 
blood  of  the  gouty.  It  is  stated  to  be  in  normal  amount,  even 
where  there  is  renal  degeneration.  But  little  loss  of  albumen 
occurs  in  gouty  nephritis.  Garrod  never  found  increase  of  albu- 
men in  blood  from  a  gouty  person,  but  believes  that  the  specific 
gravity  of  the  serum  of  the  blood  in  gout  is  lower  than  in  other 
diseases,  with  the  exception  of  albuminuria  and  scorbutus. 

Urea It  has  not  been  shown  that    excess  of  urea  occurs  in 

the  blood  in  the  earlier  stages  of  gout.  The  research  is,  however, 
beset  with  difficulties.  In  all  cases  of  granular  kidney-disease, 
there  is  probably  increase  of  urea  in  the  blood.  The  amount  is 
doubtless  in  relation  to  the  degree  of  renal  inadequacy,  however 
aetiologically  induced. 

Oxalic  Acid Oxalic  acid  has  been  frequently  found  by  Garrod 

in  the  blood  of  the  gouty,  and  is  believed  by  him  to  occur  chiefly 
in  the  paroxysmal  stages,  being  derived  by  oxydation  from  uric 
acid. 

In  blood  drawn  from  a  gouty  patient,  Ebstein  found  that 
xanthin  and  hypoxanthin  were  formed  on  exposing  it  in  a  warm 
chamber,  while  minute  quantities  of  uric  acid  disappeared. 

1  According  to  Sir  W.  Gull,  fibrin  is  increased  in  painful  affections. 


CHAPTER  VI. 

UROLOGY  OP  GOUT. 

In  discussing  the  pathogeny  of  gout,  reference  was  made  to  the 
fact  that,  both  in  the  truly  gouty  and  in  those  goutily  disposed, 
there  might  be,  occasionally,  uratic  deposits.  The  latter,  though 
not  alone  significant  of  gouty  habit,  were  shown  to  be  more  fre- 
quent and  persistent  in  that  condition. 

A  study  of  the  whole  question  of  the  changes  observable  in 
this  secretion  in  gout  is  necessarily  a  very  large  and  complex 
one,  and  relates  not  only  to  the  important  point  respecting  uric 
acid  and  its  salts,  but  to  every  constituent  of  this  fluid.  It  is 
complementary  to  a  study  of  the  associated  changes  in  the  blood, 
and  a  similar  inquiry  should  be  addressed  to  the  secretions  of  the 
skin,  if  we  would  obtain  a  deeper  insight  into  the  humoral  rela- 
tions of  gouty  pathogeny.  I  propose  to  discuss  the  conditions 
of  the  urine  :  (i.)  in  the  pras-paroxysnial  stages  of  gout ;  (2.)  in 
acute  paroxysmal  gout ;  (3.)  during  the  intervals  of  such  attacks  ; 
(4.)  in  chronic  or  cachectic  gout;  (5.)  in  incomplete  gout;  and 
lastly  (6.),  in  that  known  as  gouty  glycosuria.  The  points  to  be 
noted  in  any  case  are :  the  quantity  passed,  density,  acidity,  amounts 
of  urea,  uric  acid,  fixed  salts,  and  the  organic  constituents. 

1.  Urine  in  Prae-Paroxysmal  Stage. — It  has  occasionally  been 
observed  that  free  emission  of  a  pale  and  watery  urine  has 
occurred  before  an  acute  articular  attack.  Scudamore  noted 
this,  and  remarked  that  it  was  only  seen  in  persons  whose 
constitutions  were  much  weakened  by  gout.  I  have  inquired  for 
this  symptom  in  many  cases,  and  have  occasionally  met  with  it.1 

1  It  was  marked  in  the  case  of  an  army-surgeon,  aged  forty-eight,  under  my  care, 
who  inherited  gout  from  his  father  and  grandfather,  had  lived  freely,  and  had  many 
attacks  of  gout,  the  first  at  the  age  of  twenty-nine.  He  noted  that  his  urine  was 
very  copious  and  pale  for  from  five  to  seven  days  before  the  attacks,  and  on  one 
occasion  it  had  been  so  for  three  weeks  before  a  paroxysm.  He  was  much  broken 
down,  had  suffered  from  shingles,  and  from  attacks  of  eczema. 


URINE   IN  ACUTE    GOUT.  I  I  9 

There  is  commonly  a  diminution  of  the  principal  ingredients, 
in  particular  of  the  uric  and  phosphoric  acids  and  the  pigments. 
Urea  has  been  found  deficient  before  an  acute  attack.  Traces  of 
albumen  may  occur. 

A  steady  increase  in  the  excretion  of  uric  acid  and  urea  in 
persons  goutily  disposed  has  led  M.  Lecorche'  to  prognosticate 
the  onset  of  primary  acute  attacks. 

2.  Urine  in  Acute  Paroxysmal  Gout. — In  acute  gout  the  urine 
commonly  presents  ordinary  febrile  characters.  The  quantity  is 
found  to  vary,  but  is,  as  a  rule,  somewhat  diminished.  The  fact 
is  that,  in  acute  gout,  as  I  shall  show  later,  there  is  commonly 
present  only  a  moderate  degree  of  pyrexia. 

Hence,  the  water  may  not  be  much  reduced  in  many  cases. 
In  acute  attacks  supervening  in  the  subjects  of  chronic  gout,  the 
urine  is  less  "  febrile,"  and  may  be  passed  in  full  amount. 

Density. — The  density  varies  in  relation  to  the  excretion  of 
water,  and  especially  of  the  several  constituents  in  solution. 
With  respect  to  all  examinations  of  urine  made  during  a  par- 
oxysm, regard  must  be  had  to  the  diet  employed,  which  mate- 
rially affects  the  results. 

Taking  the  mean  density  in  ten  cases  of  acute  gout,  I  find 
1. 020,  or  the  average  of  health,  as  the  figure,  the  highest  being 
1.028,  and  the  lowest  1.015.  Other  observers  mention  1.007— 
1.025.  A  common  mean  is  1.014.  The  higher  densities  re- 
present concentration  of  the  urine  to  some  extent,  and  the  colour 
is  also  similarly  influenced.  A  high  density  has  been  observed 
to  prevail  in  the  urine  of  many  members  of  families  who  inherit 
gouty  proclivity. 

In  acute  gout  the  reaction  is  uniformly  acid,  especially  for  the 
first  few  days.  This  is  attributed  by  Lecorche  to  its  concentra- 
tion, since  at  that  time  there  is  diminished  excretion  of  uric  and 
phosphoric  acids.  The  acidity  falls  towards  the  end  of  the 
attack. 

Acidity. — The  acidity  in  health  varies  according  to  the  state  of 
digestion,  and  also  in  relation  to  the  time  of  repose.  Urine  is 
alkaline  after  a  meal,  and  most  acid  during  fasting  and  after 
sleep,  at  which  periods  there  is  least  excretion  of  carbonic  acid 
from  the  lungs.  The  acidity  is  due  to  acid  phosphate  of  sodium. 
It  may  occasionally  be  due  to  excess  of  acid  urates,  or  to  hippuric 
acid,  the  latter  especially  after  a  vegetable  or  fruity  diet.  (Garrod 
is  of  opinion  that  the  presence  of  uric  acid  has  no  influence  on 
the  acidity.)  The  reaction  of  health,  however,  is  in  relation  to 
that  of  the  phosphates,  whether  they  be  acid,  neutral,  or  basic. 


120  UROLOGY    OF    GOUT. 

As  Bence  Jones  showed,  when  the  urine  is  very  acid,  there  inay 
be  but  little  uric  acid  present  in  it,  and  when  the  latter  is  largely 
present,  the  urine  is  sometimes  neutral  in  reaction. 

Urea. — As  already  mentioned,  urea  has  been  found  deficient 
before  an  acute  attack  of  gout.  Garrod  found  in  the  case  of  a 
man,  set.  fifty-seven,  that  the  mean  excretion  was  320  grains, 
which,  considering  his  age,  was  a  fair  amount.  But  few  analyses 
of  urea-excretion  have  been  made  in  acute  gout.  Such  as  are 
recorded  indicate  that  no  material  variation  from  the  normal  is 
to  be  expected,  and  it  appears  to  be  proved  that  such  variation 
as  exists  is  in  no  relation  to  the  amount  of  uric  acid  excreted  at 
the  same  time.  Diminution  during  the  paroxysm  is  attributed 
to  loss  of  appetite,  and  to  the  simple  diet  employed  during  the 
attack.  The  relation  of  urea  to  uric  acid  in  health  in  the  adult- 
is  given  by  Lecanu  l  and  Dr.  Haig  as  I  to  33,  and  the  latter 
found  in  his  researches  on  "  uric  acid  headache  "  that  the  excre- 
tion of  urea  in  these  cases  was  practically  not  interfered  with, 
while  that  of  uric  acid  fluctuated  much,  and  specifically,  in  rela- 
tion to  headaches. 

It  would  be  remarkable  if  urea  were  not  increased  during  the 
febrile  period  of  gout,  since  it  is  increased  in  all  acute  diseases, 
and  especially  during  pyrexia. 

In  a  number  of  gouty  cases  examinations  of  the  urine  were 
made  by  Dr.  Mortimer  Granville.2  He  found  that  there  was  no 
increased  proportion  of  urea  in  most  of  them. 

Uric  Acid. — Persistent  excess  of  uric  acid  in  the  urine  is  always 
significant  of  some  important  constitutional  state,  and  indicates 
increase  of  tissue-metabolism  in  some  particular  organ  or  organs, 
or  even  throughout  the  whole  body. 

Non-elimination  of  uric  acid  has  been  proved  by  Garrod  to  be 
a  marked  and  constant  feature  of  paroxysmal  gout.  In  seven 
such  cases  he  found  the  mean  out-put  to  be  less  by  about  five 
grains  than  the  normal, — 3.62  grains  as  against  8.569  grains. 
With  this  defective  elimination  by  the  kidneys  there  is  simul- 
taneous retention  of  it  in  the  blood,  or,  at  all  events,  within  the 
body.  Dr.  Haig  has  recently  studied  these  phases  of  uric  acid 
retention,  and  believes  that  the  acid  may  be  stored  in  the  liver 
and  spleen.  He  has  shown  that  gouty  manifestations  are  apt  to 
occur  with  excess  of  uric  acid  in  the  blood,  and  can  be  checked 
by  means  which  cause  its  retention  in  the  system — liver  and 
spleen.     In  health,  the  excretion  of  it  is  greatest  during  the  alka- 

1  Lecanu,  Joum.  de  Pharmacie,  t.  xxv.  p.  261. 

2  Med.  Press  and  Circular,  March  9  and  23,  1887. 


URIC  ACID  AND  PHOSPHATES  IN  URINE  IN  ACUTE  GOUT.     12  I 

line  tide  of  digestion,  as  shown  by  Roberts,  and  Dr.  Haig  regards 
this  as  a  washing  out  of  the  uric  acid  accumulated  in  the  liver 
and  spleen  during  the  acid  tide  of  sleep,  and  not  entirely  due  to 
increased  formation  during  digestion.  In  gout  there  is  probably 
no  defective  formation-  of  uric  acid,  but  the  reverse ;  and  reten- 
tion, stasis,  and  defective  elimination  of  it  constitute  malign  faults 
attendant  on  a  paroxysm. 

Hence,  Garrod's  theory  as  to  deficient  excreting  power  in  the 
kidneys  in  respect  of  uric  acid  during  a  paroxysm  of  gout,  and  the 
very  fair  argument  in  favour  of  this  afforded  by  the  free  elimina- 
tion of  it  by  the  kidneys  in  other  states,  such  as  in  leucha3mia 
and  hepatic  disease,  where  uric  acid  formation  is  also  largely 
increased.  It  is  probable  that  the  excretion  of  uric  acid  in  gout, 
could  it  be  watched  from  hour  to  hour,  would  be  found  to  vary 
considerably.  Garrod  showed  that  in  the  early  stages  of  an 
attack  the  out-put  was  small,  and  gradually  increased  above 
the  normal  excretion  till  the  paroxysm  subsided,  when  it  again 
diminished.  The  antagonism  is  therefore  between  retention  in 
the  system  and  elimination  by  the  kidneys,  and  there  probably  is 
not,  as  has  been  supposed,  "  a  rupture  of  equilibrium  between 
production  of  the  acid  and  its  elimination  "  {Rendu). 

In  iooo  grains  of  morning  urine  in  a  case  of  acute  gout, 
Sansom  found  .830  grains  of  uric  acid;  in  one  of  chronic  gout, 
.120  grains — a  comparative  experiment  in  a  healthy  person  yield- 
ing .250  grains.1 

M.  Lecorche's  researches  on  the  elimination  of  uric  acid  by  the 
urine  in  gout  are  the  most  exact  I  have  met  with.  He  has 
shown  that  the  out-put  is  diminished  before  an  acute  attack, 
and  is  low  for  several  days — two  to  four — during  the  paroxysm, 
increasing  much  above  the  normal  the  third  and  following  two 
days,  and  again  falling  to  normal  towards  the  close  of  the  attack. 
Hence,  according  to  Lecorche,  the  greatest  elimination  occurs  at 
the  height  of  the  paroxysm,  and  not  at  the  end  of  it,  as  found 
by  Garrod. 

Phosphates. — It  has  been-  asserted  that,  along  with  uric  acid, 
there  is  also  retention  of  phosphates  in  acute  gout.  Bence  Jones, 
Parkes,  Booker,  and  Stockvis  have  demonstrated  this  fact.  The 
latter  found  in  a  case  of  gout  that  the  phosphoric  acid  in  com- 
bination with  earths  was  diminished  in  comparison  with  other 
phosphates,  not  only  during  the  paroxysms,  but  in  the  intervals. 
One-third  of  the  phosphoric  acid  excreted  daily  is  combined  with 
the  earthy  oxydes — calcium  and  magnesium.      Parkes  conceived 

1  Quoted  by  Beale  ill  "Urine,  Urinary  Deposits,"  &c,  2nd  edit.,  p.  162,  1864. 


122  UROLOGY    OF    GOUT. 

that,  as  phosphate  of  lime  is  a  constituent  of  tophi,  it  was  pro- 
bable that  retention  of  this  product  would  commonly  be  found  to 
occur. 

Teissier  noted  that  the  amount  of  phosphoric  acid  excreted 
was  increased  in  the  gouty.  Lecorche  found  that  it  varied 
exactly  as  did  the  uric  acid.  It  appears  probable  that  these 
contradictory  results  arise  from  examinations  made  under  very 
different  conditions.  As  with  uric  acid  and  urea,  so  with  phos- 
phoric acid,  the  amount  excreted  is  certain  to  vary  according  to 
the  state  of  the  patient's  nutritive  powers  and  his  capacity  for 
taking  and  digesting  food.  If  we  accept  the  view  that  there  is 
retention  of  phosphoric  acid  in  paroxysmal  gout,  we  can  hardly 
attribute  any  of  the  specific  phenomena  of  the  disorder  to  it 
alone,  though  we  have  here  a  factor  which  helps  to  explain  the 
acknowledged  diminution  of  the  alkalinity  of  the  blood  in  these 
cases,  and  the  tendency  to  uratic  precipitation  in  the  tissues. 
W.  Gairdner  noted  very  free  discharge  of  phosphates  after  par- 
oxysms of  gout. 

Hippuric  Acid. — This  never  forms  a  deposit.  W.  Budd  found 
in  some  specimens  of  urine  from  cases  of  gout  a  flocculent  pre- 
cipitate consisting  of  benzoic  acid,  which  probably  resulted  from 
decomposition  of  hippuric  acid.1 

Sulphuric  Acid. — Parkes  found  this  in  normal  amount,  and 
assumed  that  there  was  no  change  as  to  retention  or  metabolism 
of  sulphur-holding  tissues. 

Pigments. — The  urine  is  commonly  of  full  amber  colour  in  the 
gouty.  The  pigments  are  frequently  increased,  the  urine  some- 
times being  red.  The  great  affinity  of  urates  for  urinary  pig- 
ments is  well-known,  and  thus,  in  acute  gout,  deposits  of  the 
former  are  apt  to  be  highly  charged  with  the  latter,  and  so  to 
express  the  exact  tint  in  each  specimen.  They  are  derived  from 
urobilin  and  from  hsematin.  Sometimes  pale  urine,  deficient  in 
pigments,  is  passed  before  and  during  a  paroxysm  (vide  p.   188). 

As  often  happens,  with  deficiency  of  ordinary  pigments,  there 
is  in  gout  increase  of  uroxanthin.  This  occurs  in  acid  urines, 
sometimes  with  deposit  of  uric  acid,  and  may  be  demonstrated 
by  heating  with  strong  acids  which  cause  red,  blue,  and  green 
coloration.  In  one  instance  Parkes  found  a  large  amount  of 
indigo  on  adding  hydrochloric  acid. 

Albumen. — In  cases  of  paroxysmal  gout,  certainly  during  the 
earlier  attacks,  there  is  usually  no  passage  of  albumen.      With 
increasing  frequency  of  attacks,  the  kidneys  becoming  gradually 
1  Quoted  by  Beale,  op.  cit.,  1864,  p.  165. 


ALBUMINURIA,    GLYCOSURIA,    ETC.,    IN    ACUTE    GOUT.        I  23 

involved,  a  trace  of  albumen  is  apt  to  be  found.  Its  presence  is 
therefore  in  relation  to  the  degree  of  renal  inadequacy,  and  the 
ability  of  the  kidneys  to  withstand  the  additional  stress  thrown 
on  them  by  the  metabolic  changes  proper  to  the  pyrexia  and  to 
the  specific  characters  of  the  attack.  Amongst  the  latter  may 
be  reckoned  irritation  of  tubular  epithelium  by  excess  of  uric 
acid  eliminated. 

Some  degree  of  tubal  catarrh  may  thus  be  set  up  in  kid- 
neys which  are  only  slowly  undergoing  cirrhosing  change,  and 
which  may  be  expected  to  pass  off  with  remission  of  the  acute 
attack. 

The  albuminuria  of  acute  gout  is  always  fleeting,  not  lasting 
more  than  two  or  three  days. 

According  to  Lecorche,  it  appears  to  be  in  relation  to  the 
excretion  of  uric  acid  being  present  about  the  third  and  fourth 
days  of  the  attack,  and  diminishing  along  with  the  uric  acid. 

Glucose. — A  small  quantity  of  glucose  may  sometimes  be  found 
in  the  urine  during  a  gouty  paroxysm.  This,  like  the  albumi- 
nuria in  such  cases,  is  but  fugitive,  and  almost  certainly  owns  a 
hepatic  origin. 

The  urine  in  acute  gout  has  a  strong  ' '  urinous  "  odour.  It 
undergoes  little  change  on  standing  after  uratic  sediments  are 
precipitated,  and  from  its  marked  acidity  is  little  prone  to  fer- 
mentative process. 

Sediments,  and  Microscopical  Characters  thereof. — Mucous  cor- 
puscles and  epithelium  from  various  parts  of  the  urinary  channels 
may  be  found  in  the  sediment,  together  with  deposits  of  amor- 
phous pigmented  urates  and' uric  acid. 

It  is  probable  that  the  unduly  acid  condition  of  the  urine  leads 
to  such  irritation  of  the  urinary  passages  as  may  cause  some  pro- 
liferative formation  and  shedding  of  the  epithelial  linings  of  their 
coats.  Mucous  clouds  may  be  suspended  in  the  urine,  sometimes 
containing  small  crystals  of  urates. 

3.  Condition  of  the  Urine  in  the  Intervals  between  Gouty 
Paroxysms. — It  is  obvious  that  great  variations  must  exist  in  the 
condition  of  the  urine  in  the  intervals  between  gouty  paroxysms, 
these  being  determined  according  to  the  length  of  the  inter- 
paroxysmal  periods,  the  age  and  general  nutritive  state  of  the 
patient,  and,  more  especially,  by  the  presence  of  gouty  cachexia. 
In  younger  persons  of  sound  constitution,  if  care  be  exercised  in 
maintaining  health  and  in  avoidance  of  dietetic  errors — whereby 
long  intervals  may  be  predicted  between  acute  attacks — no 
marked  abnormal  features  prevail.      In  cases  of  chronic  gout  or 


124  UROLOGY    OF    GOUT. 

of  gouty  cachexia,  other  characters  obtain  which  will  be  presently 
described. 

Phosphates. — Stokvis  found  diminution  of  phosphoric  acid  in 
combination  with  earths  in  the  intervals  of  gouty  paroxysms  as 
well  as  during  acute  attacks.  The  condition  of  the  bones  should 
be  considered  in  relation  to  excretion  of  phosphates. 

Ebstein  quotes  Bramson  and  Marchand  as  authorities  for  the 
fact  that,  in  the  apparently  healthy  bones  of  two  gouty  indi- 
viduals, there  was  a  diminution  of  the  earthy  phosphates  and 
carbonates. 

4.  Urine  in  Chronic  or  Cachectic  Gout— Uric  Acid. — The  result 
of  analyses  in  these  cases  indicates  that  the  excretion  of  uric  acid 
is  rather  below  the  normal  amount. 

Bartel  found  in  one  case,  in  an  infirm  person,  diminished 
excretion  of  uric  acid  during  attacks  of  gout,  and  in  a  case 
of  chronic  gout  he  found  an  excretion  of  0.225  gramme  per 
diem.1 

Urea. — Urea  appears  in  normal  quantity,  or  veiy  nearly  so, 
unless  there  is  renal  inadequacy  due  to  some  degree  of  inter- 
stitial nephritis.  With  defective  excretion  of  uric  acid  there  is 
tendency  to  retention  in  the  blood  or  in  the  system,  and,  so  far, 
a  constant  liability  to  paroxysmal  gouty  recurrence.  Garrod 
believes  that  the  kidneys  lose  to  some  extent  their  function 
of  excreting  uric  acid  in  chronic  gout.  We  are  justified  by 
study  of  the  morbid  anatomy  of  chronic  gout — the  only  form 
of  its  anatomy  of  which  we  have  knowledge — in  believing  that 
some  measure  of  inadequacy  is  present  in  all  cases  coming  under 
this  category,  and,  hence,  may  believe  that  there  are  sufficient 
structural  defects  to  account  for  insufficient  elimination. 

The  amount  of  urea  excreted  is  almost  certainly  in  relation  to 
the  particular  diet  employed  in  each  case,  and  to  the  extent  of 
metabolic  force  available  in  the  liver. 

Phosphates. — The  same  must  be  said  in  respect  of  the  excre- 
tion of  phosphoric  acid.  Further  researches  are,  however,  much 
needed  to  complete  our  knowledge.  Such  as  have  been  made 
are  contradictory,  and  the  probability  is  that  they  have  been  con- 
ducted under  very  different  conditions  in  patients  variously  affected 
with  gout,  and  without  regard  to  the  special  diet  employed,  or 
the  capacity  in  each  case  for  its  due  assimilation. 

The  urine  in  chronic  gout  often  presents  the  characters  of  that 
excreted  by  patients  the  subject  of  chronic  interstitial  nephritis, 

1  Deut.  Archiv.  f.  Min.  Med.,  Bd.  i.  p.  30,  1866;  Nierenkrankheiten,  v.  Ziemssen's 
spez.  Path.  u.  Therap.,  Bd.  x.  p.  375.     Leipsic,  1875.     (Quoted  by  Ebstein.) 


URINE  IN  CHRONIC  AND  IN  INCOMPLETE  GOUT.         I  25 

which  condition,  indeed,  is  just  what  is  present  in  so  many  of 
these  cases. 

Polyuria  Common. — The  urine  may  be  copious  in  amount,  from 
three  to  four  pints  daily,  pale  bright,  often  frothy  when  passed,  of 
low  range  of  specific  gravity,  1.005  to  1.015,  containing  some- 
times a  trace  of  albumen,  or  for  long  periods  none,  throwing 
down  a  slight  mucous  deposit,  and  occasionally  a  few  hyaline  or 
granular  casts,  some  renal  epithelium,  seldom  fatty.  Several 
micturitions  are  common  during  the  night.  In  such  cases,  asso- 
ciated cardio-vascular  and  retinal  changes  may  be  looked  for. 

It  often  happens  that  the  patient  is  satisfied  with  this  con- 
dition of  his  urine,  believing  the  secretion  to  be  in  a  more  healthy 
state  than  when  dark,  more  scanty,  and  loaded.  The  practitioner 
will  form  a  different  opinion  on  reviewing  the  whole  features  of 
the  case.  Hence,  it  is  proper  to  examine  the  urine  at  intervals  in 
all  cases  of  chronic  gout,  and  to  meet  any  indications  as  they  arise. 

Albumen. — Some  degree  of  albuminuria  is  common  in  chronic 
gout.1  The  albumen  is  not  present  in  large  amount,  and  the 
urine  has  the  ordinary  characters  of  that  passed  by  the  subjects  of 
chronic  sclerosing  or  interstitial  nephritis.  Thus,  albumen  may  be 
present  in  small  quantities,  and  fugitive,  sometimes  disappear- 
ing for  long  periods,  and,  hence,  the  presence  of  this  abnormal 
constituent  is  not  necessary  in  order  to  justify  diagnosis  of  pro- 
gressively granulating  kidneys.  Other  characters,  such  as  poly- 
uria and  low  specific  gravity,  due  to  deficient  urea  and  salts, 
afford  sufficient  presumption  of  renal  change. 

Albuminuria  is  sometimes  the  leading  symptom  of  visceral 
gout,  falling  mainly  upon  the  kidneys. 

5.  The  Condition  of  the  Urine  in  Incomplete  Gout — By  in- 
complete gout  is  signified  imperfectly  developed  gout.  Many 
cases  may  fairly  be  placed  in  this  category  which,  while  they 
manifest  many  of  the  phases  of  well -recognized  goutiness,  yet 
present  no  classical  or  paroxysmal  features  of  the  disorder.  Many 
terms  have  been  used  to  indicate  this  condition,  thus  "  latent," 
"  masked,"  "  lurking  "  gout  have  been  described.  It  is  desirable 
to  employ  none  of  these  terms,  and  it  is  wiser  to  recognize  the 
real  underlying  habit  of  body  which  exists  in  such  cases. 

1  In  sixty-one  cases  of  gout  occurring  in  hospital  practice  examined  by  Pye- 
Smith,*  there  was  albuminuria  in  seventeen  instances  ;  in  another  case,  where  it  was 
absent,  the  kidneys  were  found  after  death  to  be  granular  and  contracted.  In  two 
instances  there  was  eclampsia,  apparently  of  renal  origin,  so  that  this  affection  probably 
existed  in  at  least  a  third  of  the  cases. 

*  Guy's  Hosp.  Pteports,  1873. 


126  UEOLOGY    OF   GOUT. 

Many  of  the  symptoms  thus  described  are  due  to  visceral  gout, 
and  these  naturally  vary  much  according  to  the  organs  involved. 
Many  of  the  vague  pains  and  aches  to  which  gouty  persons  are 
obnoxious  are  due  to  incomplete  outcome  of  the  disorder,  and  are 
commonly  considered  and  treated  as  "  rheumatic,"  often  without 
success.  Both  sexes  suffer,  women,  perhaps,  more  often  than 
men.  I  am  only  here  concerned  with  the  condition  of  the 
urine  in  cases  which  may  be  considered  typical  of  the  state 
referred  to,  and  it  is,  in  truth,  much  the  same  as  that  already 
described  in  respect  of  urine  in  the  prae-paroxysmal  stage  of  gout. 
Thus,  the  urine  is  apt  to  be  loaded  and  to  deposit  lithates.  It  is 
high-coloured,  very  acid,  and  strongly  urinous  in  odour.  The 
urina  sanguinis  is  unduly  acid,  the  urina  cibi  often  alkaline,  apt 
to  be  turbid  and  to  throw  down  phosphates.  Micturition  is  more 
frequent  than  usual.  Oxalates  with  mucus,  as  a  hummocky 
cloud,  may  sometimes  occur  as  a  deposit.  Albumen  and  glucose 
are  absent  as  a  rule,  but  there  may  be  fleeting  glycosuria  to  slight 
extent.  Many  cases  of  lithiasis  fall  under  this  category.  Dietetic 
errors,  and  excess  in  wines,  fruit,  or  rich  food,  will  speedily 
aggravate  the  conditions  just  described,  and  often  induce  vague 
pains  both  in  the  liver,  the  head,  and  various  joints. 

Some  sufferers  so  far  recognize  for  themselves  the  gouty  nature 
of  their  troubles,  thus  induced,  that  they  purposely  indulge  fur- 
ther in  gout-provoking  diet  with  a  view  to  induce  a  regular  attack, 
and  so  render  an  incomplete  attack  complete.  This  is  not  always 
achieved,  however,  and  paroxysms  are  not  readily  to  be  induced 
in  some  persons,  and  rarely  in  the  aged,  or  those  already  broken 
down  in  health.  There  is  often  an  atonic  condition,  or  an  absence 
of  all  the  elements  necessary  to  induce  complete  gout  in  the  sub- 
jects of  the  incomplete  form  of  the  disorder.  In  particular,  there 
is  insufficient  nervous  activity,  and  nutritive  metabolism  is  pos- 
sibly insufficiently  vigorous  for  its  production. 

In  some  cases,  where  articular  manifestations  are  in  abeyance 
or  only  slightly  manifested,  various  other  troubles,  such  as  eczema, 
phlebitis,  hepatalgia,  dysassthesiae,  palpitations,  headache,  or  neu- 
ralgia, often  occipital  or  cervico-brachial,  supervene,  and  nothing 
short  of  anti-gouty  medication  will  afford  relief. 

6.  Gouty  Glycosuria. — The  occurrence  of  fugitive  traces  of  glu- 
cose in  the  urine  passed  during  paroxysmal  gout  has  been  already 
referred  to.  Saccharine  urine  may  occur  at  intervals  in  cases  of 
incomplete  gout,  and  may  alternate  with  deposits  of  uric  acid. 
Confirmed  gouty  glycosuria  may  pass  into  chronic  diabetes,  and 
a   parallel    condition   is  thus  established   with  albuminuria,   the 


GOUTY   GLYCOSURIA.  \2J 

presence  of  glucose  being  the  indication  of  a  variety  of  visceral 
gout  effecting  the  liver. 

Dr.  Bence  Jones  was  amongst  the  first  to  direct  attention  to 
gouty  or,  as  he  termed  it,  intermittent  glycosuria.  In  France, 
diabetic  patients  have  long  been  placed  in  the  two  categories  of 
lean  and  fat.  Amongst  the  latter  are  many  of  the  class  under 
consideration. 

Garrod  observed  the  onset  of  glycosuria  in  gouty  patients  who 
thereafter  became  free  of  most  of  their  gouty  symptoms,  and  he 
surmised  that,  the  solids  of  the  urine  being  carried  off  by  the 
polyuria,  uric  acid  was  no  longer  retained  in  the  system.  He 
found  the  intervals  between  the  attacks  lengthened,  or  the  par- 
oxysmal tendency  prevented  in  cases  with  free  flow  of  urine, 
while  in  those  cases  in  which  no  polyuria  occurred,  although 
much  glucose  was  passed,  acute  attacks  still  occurred.  In  such 
cases  he  believes  the  uric  acid  to  be  incompletely  removed  from 
the  system. 

In  pronounced  cases,  well-marked  exacerbations  occur,  and 
sometimes  with  more  or  less  distinct  gouty  symptoms,  articular  or 
visceral.  The  quantity  of  urine  is  increased,  and  may  be  double 
the  normal  amount.  In  some  cases  the  quantity  is  below  the 
normal  out-put.  The  colour  may  vary  from  bright  amber  to  that 
of  pale  straw.  The  specimen  strongly  refracts  light,  is  markedly 
acid,  and  unusually  void  of  deposits.  The  amount  of  glucose 
may  vary  greatly.  Sometimes  the  urina  sanguinis  is  more  impreg- 
nated than  the  urina  ciii  in  the  same  case.  From  three  to 
fifteen  per  cent.,  or  more,  may  be  present ;  according  to  Lecorche, 
thirty  to  forty  grammes  per  litre.  Lithates  are,  as  a  rule,  never 
precipitated  in  urine  of  this  class,  but,  occasionally,  uric  acid  sand 
may  occur  as  a  deposit,  and  alternate  with  glucose.  In  persons  of 
gouty  heritage,  in  youth  and  in  early  adult  life,  a  small  amount 
of  glucose  may  be  present  together  with  an  increased  excretion 
both  of  uratic  and  phosphatic  salts,  not  generally  exceeding  one 
or  two  per  cent.  This  condition  is  commonly  amenable  to  suit- 
able treatment,  but  demands  recognition  as  early  as  possible. 


CHAPTER  VII. 

HEREDITARY  AND  ACQUIRED  GOUT.  ATAVISM 
IN  GOUT. 

Gout  is  commonly  described  as  a  hereditary  and  also  as  an 
acquired  disease.  The  history  of  the  greater  number  of  cases 
affords  illustration  of  the  influence  of  heredity  in  varying  degree, 
and  amongst  the  upper  classes  of  society  this  factor  is  not  often 
far  to  seek.1  Where  ancestral  history  is  obtainable  with  any  degree 
of  accuracy,  a  disorder  like  gout,  at  all  events  in  its  regular  form, 
is  not  likely  to  be  forgotten  or  mistaken,  and  any  record  of  the 
disease  in  its  ' '  chalky  "  or  tophaceous  form  cannot  be  wrongly 
interpreted.  It  is,  however,  often  difficult  to  discriminate  in  the 
accounts  given  by  patients  whether  they,  their  ancestors,  or  rela- 
tions have  suffered  from  ailments  truly  gouty  or  truly  rheumatic ; 
and  this  is  especially  hard  to  determine  if  gout  has  occurred  in 
an  irregular  or  incomplete  form. 

History  of  both  gout  and  rheumatism  is  common  in  the  fami- 
lies of  gouty  sufferers,  and  in  such  cases  it  is  proper,  I  believe, 
to  have  regard  to  the  presence  of  an  arthritic  diathesis  as  im- 
planted in  the  stock,  with  potentiality  for  evolution  in  either 
direction,  according  to  the  special  environments  of  each  individual 
thus  originally  impressed. 

It  is  certain  that  this  diathesis  is  widely  spread,  and  that  by 
intermixture  many  and  varied  phases  of  its  presence  are  witnessed. 
This  is  true  of  all  diathetic  states.  So  much  is  this  the  case,  that 
it  naturally  becomes  very  difficult,  if  not  actually  impossible,  to 
affirm  with  certainty  that  in  any  given  instance  a  disorder  is 
actually  acquired  de  novo.  A  study  of  life-histories  over  long 
periods,  conducted  by  the  light  of  modern  views  as  to  evolution, 

1  In  a  pedigree  extant  at  the  Heralds'  College  it  is  gravely  stated  that  our  com- 
mon ancestor  Adam  died  of  the  "  Gowte  "  !  (Compiled  by  a  monk,  probably  in  the 
thirteenth  or  fourteenth  century. ) 


ACQUIRED    GOUT.  I  29 

points  very  conclusively  to  the  fact  that  tendencies  in  families  and 
individuals  may  lie  long  dormant,  may  even  be  repressed  in  cer- 
tain lives,  and  yet  reappear  in  later  members  of  the  same  stock 
under  certain  provocatives.  This  up-cropping  of  tendencies  is  so 
plainly  seen  in  many  instances,  that  it  is  only  fair  to  recognize  the 
possibility  of  it  in  others  where  no  history  is  available  or  readily 
forthcoming  to  explain  it. 

By  tendency,  in  the  case  under  consideration,  I  mean  tissue- 
peculiarity  or  potentiality,  whereby  certain  textures  are  so  im- 
pressed as  to  undergo,  in  course  of  time,  definite  trophic  changes 
in  response  to  definite  exciting  causes  which  lead  to  the  evolution 
of  gout  or  gouty  manifestations. 

It  is  seldom  possible,  I  believe,  in  any  case  of  gout  occurring 
in  an  individual  whose  ancestors  have  been  long  settled  in  this 
country,  to  affirm  with  certainty  that  the  disease  is  absolutely 
newly  acquired.  Many  points  in  the  case  may  favour  this  belief  ; 
but,  I  repeat,  no  certainty  is  possible.  It  is  less  difficult  to 
assume  that  the  disorder  is  acquired  when  the  individual  comes 
from  a  stock,  and  also  from  a  country,  where  gout  is  not  known 
to  have  prevailed.  In  the  cases  of  many  Irish  people  of  the 
lower  orders  who  come  to  London  and  grow  gouty,  we  may  be 
fairly  sure  that  their  progenitors  were  not  gouty,  inasmuch  as 
gout  is,  and  probably  always  has  been,  unknown  in  the  peasantry 
of  Ireland.  But  even  here  we  find  that  they  come  of  a  stock 
which  may  be  very  markedly  arthritic,  since  chronic  rheumatic 
arthritis  is  a  common  disorder  there. 

Facts,  however,  go  to  prove  that,  with  few  exceptions,  certain 
habits  of  life  and  peculiarities  of  diet  will  induce  gout  in  any 
people  and  in  any  country.  Over-eating  and  intemperate  drink- 
ing of  certain  alcoholic  liquors,  together  with  indolent  habits, 
prevail  too  commonly  to  induce  gout  in  all  but  a  few  climates. 
Hence,  the  fact  of  acquired  gout  must  be  accepted. 

As  pointed  out  by  Dr.  Harry  Campbell  in  his  very  suggestive 
work  on  the  "Causation  of  Disease,"1  the  power  of  acquiring 
may  be  inherited,  but  the  inheritance  of  the  acquisition  may  not 
be  entirely  implanted  in  any  case  ;  for,  if  an  individual  were  placed 
under  an  environment  incapable  of  effecting  structural  change 
or  acquisition,  it  would  never  appear  in  him.  Hence,  many 
persons  may  be  potentially  capable  of  developing  gout,  but  owing 
to  fortunate  circumstances  never  have  the  chance  of  becoming 
gouty.  This  argument  is  applicable  to  any  diathetic  condition. 
Per  contra,  many  persons  are  potentially  incapable  of  developing 

1  Page  140,  1S89. 

1 


I30        HEREDITARY  AND  ACQUIRED  GOUT. 

gout  or  rheumatism,  or  any  manifestation  of  the  arthritic  habit 
of  body. 

Statistics  culled  from  English,  French,  and  German  practice 
go  to  prove  the  powerful  factor  of  heredity  in  gout.  Amongst 
the  upper  classes,  in  whom  more  gout  prevails,  and  whose  family 
histories  are  more  trustworthy  and  complete,  the  influence  is 
strongly  shown,  and  occurs  in  from  fifty  to  seventy-five  per  cent, 
of  the  cases.  More  complete  knowledge  of  ancestral  peculiarities 
would,  I  conceive,  allow  of  a  much  larger  percentage  in  this 
relation,  perhaps  even  ninety  per  cent,  of  all  cases.  For  the 
remainder,  acquirement  may  be  fairly  acknowledged. 

Without  doubt,  heredity  is  one  of  the  most  powerful  factors  in 
gout.  As  I  have  pointed  out  already,  the  disease  does  hot  always 
"  breed  true."  Owing,  probably,  to  intermixture  of  diatheses,  to 
reversion  to  former  conditions  of  trophic  habit,  other  forms  of 
arthritism  may  be  developed,  and  many  notable  strange  products 
along  with  them.  To  take  one  somewhat  common  example  :  the 
daughters  of  gouty '  men  are  not  infrequently  the  subjects  of 
chronic  rheumatic  arthritis.  This  may  be  merely  a  phase  of  the 
arthritic  habit,  or  a  reversion  to  a  type  of  it  long  dormant  in  the 
line  of  a  long  ancestry ;  or,  again,  it  may  be  a  compound  result 
of  blending  with  a  strain  of  strumous  proclivity  introduced  at 
some  period  into  the  family  line.  The  problem  is  so  complex 
that  it  cannot  at  present  be  unravelled.  We  may  guess,  and  we 
should  do  so,  at  the  causes  of  the  result,  and  in  time  we  may 
find  the  component  factors  and  put  them  into  their  true  rela- 
tions. Meantime,  the  features  and  evolutional  potentialities  of 
each  arthritic  case  must  be  closely  studied  with  the  trained  eye, 
mind,  and  acumen  of  the  naturalist.  This  is  the  scientific 
method  in  pathogenic  inquiry,  and  it  is  best  begun  by  a  humble 
confession  of  our  ignorance  up  to  the  present  time. 

The  study  of  hereditary  tendency  is  of  the  utmost  value  in 
clinical  work,  for,  by  knowledge  of  it,  we  have  power  to  avert, 
not  seldom,  from  individuals  the  malign  evolutions  of  inherent 
potentiality.  By  variation  of  surroundings  we  may  accomplish 
much  while  the  organism  is  still  young  and  pliant.  When  habits 
are  formed  by  definite  environment,  it  is  very  difficult  to  secure 
any  marked  variations  from  the  type  assumed. 

The  causes  of  fresh  acquirement  of  a  gouty  habit  may  be 
defined  as  relating  especially  to  ease-loving  and  luxurious  habits, 
over-indulgence  in  good  living  and  alcoholic  drinks,  deficient 
bodily  exercise,  and  exhaustion  of  the  great  nerve-centres. 

Facts  prove  that  heredity  leads  to  early  establishment  of  the 


ATAVISM.  I  3  i 

disorder,  while  acquirement  seldom  entails  gouty  symptoms  before 
the  middle  or  end  of  the  fourth  decade  of  life. 

The  prognosis  in  the  two  conditions  varies,  and  is,  on  the 
whole,  better  for  the  victim  of  acquired  habit,  especially  if  he  is 
a  prudent  and  sensible  person  with  a  strong  will,  who  can  control 
his  appetites. 

Graves  noted  as  a  distinction  between  hereditary  and  acquired 
gout,  that  in  the  former  case  arthritic  attacks  were  apt  to  come 
on  suddenly  without  the  slightest  precursory  derangement  of 
health,  or  the  operation  of  any  assignable  cause,  whereas  he  had 
seen  no  instance  of  a  similar  kind  in  acquired  gout. 

Atavism.  —It  has  been  affirmed  of  gout,  as  of  other  constitutional 
diseases,  that  it  is  apt  to  skip  a  generation,  and  reappear  in  the 
grandchildren  of  those  who  suffered  from  the  disorder.  I  must 
confess  that  I  have  seen  reason  in  many  instances  to  question  the 
truth  of  this.  Several  fallacies  beset  the  inquiry.  It  is  now  well- 
ascertained  in  biology  that  certain  characteristics  often  lie  dor- 
mant in  successive  generations,  and  that  such  latent  qualities  are 
apt  to  crop  up  from  time  to  time  in  response  to  favouring  con- 
ditions. This  common  belief  in  regard  to  gout  has  probably  had 
reference  alone  to  instances  of  overt  and  articular  attacks  of  the 
disease.  The  minor  degrees  of  the  dyscrasia,  including  the  mul- 
tiform phases  of  it  now  recognized  as  goutiness,  or  as  forms  of 
irregular  or  incomplete  gout,  have  been  much,  if  not  altogether, 
disregarded  or  unappreciated,  and  it  is  certain  that  many  of  these 
occur  in  the  children  of  the  gouty  by  direct  descent,  without 
classical  and  paroxysmal  phenomena.  These  characteristics  may 
be  so  far  suppressed  as  to  disappear  for  one  or  more  generations, 
but  may  reappear  under  due  provocation,  and  develop  into  in- 
tense manifestations.  When  all  the  circumstances  and  clinical 
histories  of  gouty  families  are  critically  reviewed,  the  facts  do  not 
lend  support  to  a  doctrine  of  pure  atavism  in  gout.  Cross-breed- 
ing and  blending  of  diathetic  states  may  do  much  to  modify 
and  check  the  inherited  proclivity,  and  careful  selection  in  alli- 
ances might,  conceivably,  be  potent  to  suppress  all  gouty  taint. 
But  the  facts  in  many  cases  do  not  lend  support  to  this  pro- 
position, and  much  labour  and  study  are  still  required  to  pro- 
duce materials  whereon  to  found  exact  and  definite  laws  in 
respect  of  inherited  taints  and  implanted  proclivities.  In  the 
meantime,  it  is  the  duty  of  the  physician  to  recognize  the 
specific  characteristics,  physiognomical,  textural,  trophical,  and 
evolutional,  which  are  distinctly  proper  to  the  manifestations  of 
the  arthritic  diathesis. 


CHAPTER   VIII. 

ON   CONDITIONS  ALLIED  TO  GOUT   IN  THE 
LOWER  ANIMALS. 

The  results  of  some  careful  studies  of  this  subject  have  not 
hitherto  thrown  much  light  on  it,  nor  been  fruitful  for  humanity. 
It  may  be  fairly  stated  that  no  disease  bearing  close  resemblance 
to  gout  during  life  has  been  met  with  in  other  animals  than 
man.  Concretions  of  uric  acid  have  been  found  in  some  reptiles 
and  birds  which  have  been  kept  in  confinement  and  under  un- 
natural conditions.  These  occurred  in  the  kidneys  and  other 
viscera  of  the  former,  and  about  the  joints  of  the  feet  in  the 
latter.  Guanin-gout  is  met  with  occasionally  in  swine.  After 
ligation  of  the  ureters  in  birds  and  removal  of  the  kidneys  in 
snakes,  masses  of  urates  have  been  found  in  the  viscera  and  on 
serous  membranes,  also  in  joints.  It  would  be  a  straining  of 
terms  to  call  this  gout.  The  latest  contribution  to  the  subject 
is  that  of  Dr.  Mendelson  of  New  York,1  who  describes  in  detail 
his  research  into  the  nature  of  guanin-gout  in  the  hog.  Guanin 
has  the  chemical  composition  C5H5N50,  and  was  first  obtained 
from  guano.  According  to  Foster,  small  amounts  are  found  in 
the  pancreas,  liver,  and  muscle-extract.  It  unites  with  alkalies, 
acids,  and  salts,  and  forms  crystallizable  compounds.  By  oxy- 
dation  it  yields,  amongst  other  substances,  small  quantities  of 
urea,  xanthin,  and  oxalic  acid.  Uric  acid  may  be  converted  by 
sodium -amalgam  into  xanthin  and  hypoxanthin.  Guanin  is  thus 
an  ally  of  uric  acid. 

Dr.  Mendelson  found  in  his  case  of  guanin-gout  in  the  hog, 
that  guanin  was  first  deposited  in  the  bone  without  signs  of 
adjacent  inflammatory  action,  the  cartilage  being  simply  pushed 
before  it.  In  the  cartilages  the  deposit  was  primarily  interstitial 
(in  the    ground-substance),   but  also   met  with   inside  the   cor- 

1  Amer.  Journal  of  the  Medical  Sciences,  February,  1888. 


GUANIN-GOUT.  I  33 

puscles.  The  needles  of  guanin  in  the  cells  were  not  parallel 
to  those  in  the  ground-substance.  Deposits  were  found  in  the 
medullary  spaces  of  bone  spreading  towards  the  cai'tilage,  and 
they  were  met  with  in  the  veins,  in  tendinous  sheaths,  and 
muscles.  He  agrees  with  Ebstein  as  to  molecular  necrosis  at 
the  site  of  deposits,  but  believes  that  in  the  hog  the  latter  are 
primary  and  the  necrosis  secondary.  The  guanin-crystals  were 
fine  and  hair-like,  and  doubly  refractive  under  the  polariscope, 
transmitting  light  when  the  Nicol  prisms  were  crossed. 

This  disorder  is  rare  in  swine,  though  it  might  be  expected  to 
be  common  under  the  conditions  of  their  lives  as  directed  for 
the  market.  It  must  be  borne  in  mind,  however,  that  they  are 
slaughtered  at  an  early  period,  and  seldom  reach  advanced  age. 

Although  these  researches  are  helpful  in  determining  part  of 
the  morbid  anatomy  and  the  pathogeny  of  gouty  deposits,  they 
afford  little  insight  into  the  more  abstruse  and  multiform  features 
of  gouty  disease  as  met  with  in  human  beings.    . 


CHAPTER  IX. 

RELATION  OF  GOUT  TO  OTHER  MORBID  STATES, 
AND  ITS  INFLUENCE  ON  THESE.  COMMINGLING 
OF  GOUT. 

Many  of  the  acknowledged  difficulties  relating  to  the  whole  sub- 
ject of  gout  are  due  to  the  peculiar  and  unquestionable  influence 
exerted  by  the  gouty  habit  of  body  upon  other  diathetic  predis- 
positions and  tendencies. 

Hitherto,  we  have  been  concerned  exclusively  with  the  changes 
wrought  by  pure  and  uncomplicated  gout.  To  describe  the  dis- 
ease as  met  with  in  daily  practice,  demands  at  this  point  a  larger 
consideration  of  the  whole  subject.  Although  classical  examples, 
both  of  articular  and  visceral  gout,  abound,  many  instances  are 
met  with  in  which  other  conditions  are  modified  variously  by 
gouty  influence. 

I  propose,  therefore,  to  treat  of  the  relations  which  exist 
(i.)  between  gout  and  rheumatism,  discussing  the  latter  in  its 
widest  sense;  (2.)  between  gout  and  lead-impregnation;  (3.) 
between  gout,  struma,  and  tuberculosis ;  (4.)  between  gout  and 
cancer;  (5.)  between  gout  and  syphilis;  (6.)  between  gout,  dia- 
betes, and  glycosuria ;  (7.)  between  gout  and  obesity;  (8.)  be- 
tween gout  and  oxaluria  ;  (9.)  between  gout  and  splenic  leuchasmia  ; 
(10.)  between  gout  and  purpura ;  (1 1.)  between  gout  and  hgemo- 
philia  ;  (12.)  between  gout  and  traumatism;  (13.)  between  gout 
and  osteitis  deformans.  I  shall  also  discuss  (14.)  the  influence 
of  the  gouty  habit  on  some  specific  febrile  and  acute  diseases, 
(i  5.)  its  influence  on  painful  affections,  and  (16.)  pygemic  arthritis 
and  gout. 

1.— The  Relation  between  Gout  and  Rheumatism. 

I  have  already  discussed  this  subject  in  part  under  the  head 
of  the  Pathogeny  of  Gout,  and  I  take  my  stand  with  those  who 


RELATION    BETWEEN    GOUT    AND    RHEUMATISM .         I  35 

regard  the  latter  as  an  offshoot  from  the  parent  arthritic  stem. 
Those  who  have  most  studied  both  diseases  will  best  appreciate 
the  difficulties  which  beset  the  truth- seeking  inquirer  in  esta- 
blishing an  exact  diagnosis  in  certain  cases.  So  pressing  are 
these  difficulties,  that  even  the  most  practised  observers  will 
sometimes  hesitate  in  pronouncing  for  one  or  the  other  morbid 
condition,  and  some  have  arrived  at  the  conclusion  that  dis- 
crimination is  often  impossible. 

My  own  observations  have  led  me  to  be  dogmatic  in  most 
instances,  and  only  doubtful  for  a  time  in  respect  of  others. 
An  exact  diagnosis  is  not  always  possible  on  the  instant,  but 
a  few  days'  observation  usually  suffices  to  clear  up  doubtful 
points. 

For  a  clear  comprehension  of  the  difficulties,  an  intimate  study, 
both  clinical  and  pathological,  of  the  features  of  each  morbid 
state  is  essential.  In  this  country  there  is  no  lack  of  material 
in  either  category,  and  if  this  vexed  question  can  be  settled 
anywhere,  it  should  assuredly  be  solved  in  the  British  Isles. 

Some  of  the  errors  which  still  prevail  on  the  subject  may  be 
traced  to  dogmatic  teaching  from  centres  where  one  or  other  of 
these  diseases — but  not  both — happens  to  be  common.  It  is  even 
now  maintained  by  some  in  this  country  that,  so  much  are  gout 
and  rheumatism  blended  and  intermixed  through  successive 
generations,  that  it  is  not  possible  to  unravel  the  problem,  and 
pronounce  with  certainty  that  this  is  pure  rheumatism  and  that 
pure  gout.  I  am  prepared  to  deny  such  an  affirmation.  My 
opinion  is  that  each  "breeds  true,"  but  that,  as  will  be  shown, 
comminglings  sometimes  occur. 

I  discuss,  first,  the  relations  between  gout  and  acute  articular 
rheumatism  or  rheumatic  fever.  Difficulty  seldom  occurs  in 
establishing  the  diagnosis  here.  Excluding  pyemic  arthritis  and 
gonorrhoeal  arthritis,  we  have  to  distinguish  between  rheumatic 
fever  and  those  rare  instances  in  which  polyarthritis  uratica 
occurs,  that  is,  gout  set  up  acutely  in  several  joints  at  the  same 
time,  or  between  rheumatic  fever  and  acute  attacks,  or  exacer- 
bations, of  chronic  rheumatic  arthritis. 

The  difficulties  here  are  clinical.  Diagnosis  is  for  the  living, 
and  not  a  puzzle  to  be  solved  by  necropsy.  Not  to  enter  fully 
into  the  differential  characters  of  the  disorders  now  under  con- 
sideration, which,  indeed,  are  known  by  any  tyro  in  medicine,  it 
may  suffice  to  indicate  that  rheumatic  fever  is  a  disease  chiefly 
of  adolescence,  and  gout  in  its  paroxysmal  forms  one  of  middle 
or  advancing  life. 


136      RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

The  antecedents  of  each  are  markedly  different,  so  that  while 
an  attack  of  rheumatic  fever  cannot  be  predicted,  a  paroxysm  of 
gout  may  not  infrequently  be  foretold  days  in  advance.  The 
pyrexia  of  the  former  is  severe,  and  may  be  dangerously  so,  while 
that  of  the  latter  is  commonly  mild,  and  hyperpyrexia  is  unknown 
in  connection  with  it.  The  acute  cardiac  troubles  and  profuse 
sweatings  of  acute  rheumatism  have  no  place  in  gouty  paroxysms. 
It  is  hardly  possible  to  speak  of  any  paroxysmal  tendency  in 
acute  rheumatism  in  the  sense  in  which  such  term  is  applied  in 
gout.  The  anasmia  induced  by  rheumatic  fever  does  not  follow 
acute  gout.  With  respect  to  the  joints  specially  affected  and 
their  appearance  in  the  cases  now  under  consideration,  there  is  a 
certain  resemblance.  In  both  rheumatic  fever  aud  acute  gouty 
polyarthritis,  large  and  small  joints  may  be  attacked  simultaneously 
or  in  succession,  and  the  degree  of  effusion  will  by  itself  hardly 
aid  in  diagnosis.  The  difficulty  of  diagnosis  is  enhanced  in  any 
instance  if  there  is,  as  there  may  be,  history  of  previous  rheumatic 
fever  in  early  life,  and  possibly  signs  of  old  cardiac  valvulitis, 
since  it  is  certain  that  the  subjects  of  true  rheumatism  may 
sometimes  grow  up  gouty. 

The  essential  distinction  is  to  be  made  by  examination  of  the 
blood  and  the  urine.  In  acute  rheumatism,  there  are  no  note- 
worthy changes  in  the  blood  in  respect  of  uric  acid,  while  the 
urine  presents  the  characters  of  that  secretion  in  ordinary  febrile 
states,  there  being  no  excess  of  uric  acid  excreted. 

In  gout,  on  the  other  hand,  there  is  plain  evidence  of  urichsemia, 
while  there  is  the  characteristic  diminution  of  uric  acid  at  the 
outset  of  the  paroxysmal  stage,  and  the  equally  significant  exces- 
sive discharge  for  several  subsequent  days. 

Therapeutical  measures  are  also  a  touch-stone  here,  since  sodium 
salicylate  is  almost  specific,  and  rapidly  so,  for  the  one,  and  col- 
chicum  inoperative  ;  the  converse  being  equally  true,  certainly  for 
a  few  days,  in  the  case  of  gouty  polyarthritis. 

It  may,  therefore,  be  affirmed  that  there  is  but  little  relation 
between  acute  polyarthritic  gout  and  acute  rheumatism,  and 
that  little  indirect.  No  one  could  venture  to  draw  an  analogy 
between  rheumatic  fever  and  acute  gouty  monarthritis.  The  only 
common  ground  for  such  morbid  states  is  that  of  the  arthritic 
habit  of  body  in  which  there  is  inherent  predisposition,  deter- 
mined by  nervous  influences  affecting  the  great  motor  centres, 
for  errors  of  nutrition  in  the  tissues  of  joints ;  and  in  virtue  of 
this  nenro-trophic  instability,  the  specific  peccant  matters  of  each 
disorder  in  question  work  out  their  mischief.      The  gouty  and 


GOUT   AND    CHRONIC   RHEUMATIC   ARTHRITIS.  1 37 

rheumatic  branches  of  the  parent  arthritic  stem  do  not  run 
parallel,  but  diverge. 

It  must,  however,  be  allowed  that  doubt  will  remain  occasion- 
ally for  a  time  in  cases  of  the  acute  form  of  rheumatoid  arthritis. 
When  these  occur  in  middle  life,  or  when  an  exacerbation  takes 
place  and  several  joints  are  affected  at  once  in  this  disorder,  the 
case  presents  many  of  the  features  of  generalized  gout.  It  is  not 
the  fact  that,  as  stated  by  some  authors,  gout  most  often  attacks 
the  robust  and  full-blooded. 

There  is  a  poor  and  atonic  true  gout,  the  appanage  of  the 
feeble  and  lowly  vitalized,  and  in  such  persons  there  is  much 
resemblance  under  the  stress  of  unequivocal  gouty  polyarthritis 
to  attacks  of  acute  rheumatoid  arthritis.  Such  cases  are  often 
for  a  long  time  obnoxious  to  any  treatment,  and,  hence,  the  thera- 
peutic tests  are  hardly  of  avail  to  clear  up  diagnostic  difficulties. 
Family  history  and  antecedents,  however,  commonly  help  here, 
and  urichsemia  is  the  abiding  factor  even  in  these  cases.1 

The  greatest  difficulty,  however,  is  sometimes  experienced  in 
making  a  differential  diagnosis  between  the  chronic  forms  of 
gouty  and  rheumatic  arthritis.  Some  of  the  most  honest  and 
careful  observers  decline  in  many  instances  to  be  dogmatic  in 
respect  of  these.  The  particular  joint  affected  may  be  a  guide  to 
diagnosis ;  thus,  if  the  shoulder-joint  be  alone  affected,  the  dis- 
order is  unlikely  to  be  gouty,  since  true  gout  in  this  part  is  of 
extreme  rarity.      Omagra  is  almost  always  rheumatic. 

The  relationship  of  gout  to  chronic  rheumatic  or  rheumatoid 
arthritis  is  one  of  such  large  importance  that  I  am  compelled  in 
considering  this  question  to  discuss  the  nosological  position  of 
the  latter  at  some  length.2 

At  the  outset,  I  think  I  may  affirm  that  London,  as  a  sphere 
of  observation,  affords,  perhaps,  the  largest  opportunities  for 
study  of  all  forms  of  articular  trouble.  We  see  the  joint-troubles 
of  all  nationalities  ;  we  have  a  large  field  for  observation  amongst 
the  Irish,  who  form  a  considerable  part  of  our  hospital  and  work- 
house inmates  and  attendants.  We  see,  without  any  doubt,  the 
largest  number  of  gouty  cases  anywhere  met  with  on  the  habitable 
globe.      We  have  scrofulous  cases  in   abundance,  and  no  lack  of 

1  In  an  analysis  of  five  hundred  cases  of  acute  rheumatism  made  by  Dr.  Syers  of 
the  Westminster  Hospital,  he  obtained  a  family  history  of  gout  in  7.6  per  cent,  of  the 
number.     Lancet,  June  30,  1888,  p.  1292. 

2  I  have  treated  this  subject  in  an  address  on  the  Nosological  Relations  of  Chronic 
Rheumatic  Arthritis,  delivered  in  Belfast,  Brit.  Med.  Journal,  August  9,  1884,  and 
in  the  Art.  "  Chronic  Rheumatic  Arthritis,"  C.  Heath's  Diet,  of  Practical  Surgery, 
1886. 


I38      RELATION   OF    GOUT    TO    OTHER   MORBID    STATES. 

unequivocal  rheumatism.  We  see  more  than  this  in  the  com- 
minglings  and  coalescence  of  all  these  forms  of  disease.  We  see, 
what  is  very  interesting  and  important — the  influence  of  London 
life  upon  persons  who  come  from  Ireland,  Scotland,  and  the  pro- 
vincial districts,  from  the  colonies  and  elsewhere,  and  who  bring 
with  them  their  peculiar  heritage  and  morbid  tendencies,  to  be 
not  seldom  modified,  more  or  less,  by  the  peculiarities  of  life  in 
our  vast  metropolis.  An  honest  observer,  seeking  the  truth  in 
London,  may  rest  assured  that  he  has  a  large  and  fair  field  for  his 
study  of  arthritis  in  all  its  forms. 

In  approaching  the  study  of  rheumatoid  arthritis,  it  is  necessary, 
in  the  first  place,  to  have  a  clear  idea  of  what  is  sought,  and  we 
must  start  with  well-defined  conceptions  as  to  the  significance  of 
certain  symptoms  and  physical  signs.  Some  might  here  join  issue 
with  me  at  once,  and,  possibly,  reject  such  definitions  as  I  pro- 
pose. Nevertheless,  I  may  confess  myself  familiar  with  rheu- 
matoid arthritis  as  it  is  recognized  in  its  purest  form  in  Scotland 
and  Ireland.  I  have  seen  it  in  the  hospitals  of  Edinburgh  and 
Dublin,  and  studied  its  morbid  anatomy  on  the  shelves  of  the 
museums  there. 

I  have  good  reason  for  taking  as  typical  such  a  case  as  would 
be  at  once  recognized  in  Scotland  or  Ireland  as  characteristic, 
and  my  reason  is,  that  in  these  countries  there  are  probably 
fewer  influences  at  work  than  in  England  to  modify  the  natural 
course  of  the  disorder ;  and,  in  particular,  there  is  practically  an 
entire  absence  of  gout  amongst  the  classes  who  furnish  the  com- 
monest subjects  of  rheumatoid  arthritis.  It  may  be  partly  for 
these  reasons  that  some  of  the  best  studies  respecting  the. disease 
have  been  conducted  in  Ireland ;  and  I  think  we  cannot  seek  a 
purer  source  of  information,  unless,  indeed,  it  be  the  exact  con- 
tributions of  the  Parisian  school  to  this  subject,  especially  those 
of  Cruveilhier,  Trousseau,  and  Charcot. 

It  may  be  certainly  affirmed  that  in  Prance  there  is  less  gout 
than  in  England,  and  in  America  gout  is  as  yet  hardly  recognized. 
So,  too,  in  Holland,  in  Germany,  and  in  Eussia,  true  gout  is 
amongst  the  rarest  of  diseases,  and  rheumatoid  arthritis  in  all 
these  countries  is  a  common  malady.  It  is  not  unimportant  to 
note  this  fact,  because  it  is  certain  that  the  descriptions  of  the 
disease  given  by  foreign  writers  better  agree  among  themselves, 
and  also  with  those  of  the  Irish  and  French  schools,  than  they  do, 
for  the  most  part,  with  some  of  those  of  the  English  school, 
particularly  as  represented  by  London. 

It   may,    I    think,  be    fairly    said,    that  but  for  English    ob- 


GOUT    AND    CHRONIC   RHEUMATIC    ARTHRITIS.  1 39 

servations  we  should  never  have  had  the  term  "rheumatic 
gout."  l 

By  rheumatoid  arthritis  I  mean  an  essentially  chronic  form  of 
joint-disease,  affecting  both  small  and  large,  one  or  many,  arti- 
culations.2 It  may  begin  insidiously,  with  pain  and  swelling 
gradually  increasing,  or  it  may  begin  by  more  acute  local  symp- 
toms. The  tissues  of  the  joint  are  affected  by  a  chronic  and 
often  progressive  inflammation,  beginning  first  in  the  synovial 
membrane,  affecting  next  the  articular  cartilage,  and  this,  perhaps, 
in  most  cases  more  severely  than  any  other  texture  ;  then  the 
ligamentous  structures ;   and,  lastly,  the  ends  of  the  bones. 

The  morbid  anatomy  varies  according  to  the  intensity  and 
duration  of  the  disease,  the  simplest  expression  of  it  being 
Heberden's  nodes  or  "  end-joint  rheumatism,"  in  which  there  is 
no  more  found  after  death  than  an  enlargement  of  the  natural 
phalangeal  tubercles,  slight  synovial  thickening,  and  expansion 
of  the  articular  cartilage.  In  its  gravest  form  there  may  be 
profound  change  in  all  the  structures  of  the  joint,  with  effusion 
into  it,  ulceration  of  cartilage,  eburnation  of  bone,  bony  and  carti- 
laginous outgrowths. 

Eheumatoid  arthritis  implies  more  or  less  deformity  and  crip- 
pling. The  term,  as  I  understand  it,  covers  all  cases  known  as 
arthritis  deformans,  osteo-arthritis,  monarthritis  (e.g.,  malum  coxae 
senile),  and  nodular  rheumatism. 

But  the  type  of  the  malady  varies  as  it  is  more  or  less  acute, 
more  or  less  general,  and,  somewhat,  according  to  the  age  and  sex 
of  the  patients ;  and  its  forms  have  been  clinically  well-described 
as  acute,  chronic,  and  irregular.  Both  sexes  are  affected,  but 
females  in  larger  proportion.  The  acute  and  general  form  is 
more  common  in  young  persons,  is  met  with  even  in  childhood, 
and  especially  in  women,  and  thus  assumes  the  characters  of  a 
severe  constitutional  disease  in  more  marked  form.  At  the  meno- 
pause, too,  the  disease  is  apt  to  be  acute  and  rapidly  progressive. 
The  smaller  joints,  especially  of  the  hands,  suffer  more  in  this 
form.  The  chronic  form,  of  more  insidious  origin,  is  met  with 
more  often  after  middle  life  and  in  the  male  sex,  affecting  more 
especially  larger  and  often  single  joints.      This  is  often  excited 

1  "  A  name  which  seems  to  have  been  invented  to  cover  the  difficulty  of  nicer 
discrimination." — Letter  on  Rheumatism  and  Gout,  addressed  to  Sir  George  Baker, 
Bart.,  P.R.C.P.,  by  John  Latham,  M.J).,  Physician  to  St.  Bartholomew's  Hospital, 
p.  69.  London,  1796.  Hay  garth  alluded  to  nodosity  of  the  joints  as  commonly 
called  "Rheumatick  Gout."  See  Clinical  History,  p.  188,  1805.  John  Hunter, 
believing  that  no  two  diathetic  conditions  could  co-exist,  was  strongly  opposed  to 
this  appellation. 

2  The  term  "rheumatoid  arthritis  "  was  first  introduced  by  Garrod  in  1858. 


140      RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

by  local  injuries.  Many  exceptional  cases,  however,  are  met  with. 
In  by  far  the  great  majority  of  cases,  there  are  no  associated 
visceral  lesions.  In  the  exceptional  instances,  these  may  often  be 
traced  to  antecedent  true  rheumatism.  I  forbear  to  describe  the 
more  minute  changes  set  up  by  the  disease.  Enough  has  been 
stated  to  differentiate  the  malady  from  other  forms  of  arthritis. 
Many  negative  symptoms  also  avail  to  distinguish  it.  I  have 
given  the  typical  characters,  and  with  these  we  are  in  a  position 
to  prosecute  further  study.  At  this  stage  of  the  inquiry  it  is 
nothing  to  the  point  to  affirm  that  such  a  malady  is  in  relation  to 
other  forms  of  arthritis.  It  may  be,  and  I  believe  is,  in  such  a 
relation,  but  we  must  have  a  recognized  type  for  comparison  at 
the  outset.  And  so  far  most  authorities  are  agreed.  It  will  not 
be  contested  that  the  only  possible  methods  for  study  of  any  dis- 
order must  proceed  on  the  lines,  first,  of  accurate  clinical  obser- 
vation, and,  secondly,  on  those  of  morbid  anatomy. 

We  get  but  incomplete  knowledge  by  the  pursuit  of  either 
method  alone,  and  it  may  be  taken  as  an  axiom  in  pathology  that 
coincidence  of  structural  changes,  as  found  in  the  dead-house,  by 
no  means  implies  identity  of  process  in  leading  up  to  them.  I 
would  say  that  some  of  the  difficulty  attending  this  subject  has 
come  from  a  forgetfulness  of  this.  Although  both  lines  of  study, 
clinical  and  pathological,  have  been  followed  in  respect  of  rheu- 
matoid arthritis,  neither  the  precise  nosological  position  nor  the 
exact  clinical  relations  of  the  disorder  have  as  yet  been  accurately 
determined.  The  whole  question  is  a  very  difficult  one.  The 
following  are  the  opinions  that  have  been  entertained  as  to  its 
pathological  origin : — 

1.  That  it  is  chronic  rheumatism. 

2.  That  it  has  no  direct  relation  to  rheumatism,  but  only  a  like- 
ness to  it ;  and  that  it  may  exist  with  or  without  a  rheumatic  or 
gouty  tendency,  and  is  in  no  way  antagonistic  to  either,  partaking 
rather  of  the  nature  of  a  senile  change,  induced  by  wear  and  tear. 

3.  That  it  is  closely  allied  to  rheumatism,  yet  presenting  some 
features  of  gout,  is  neither  rheumatic  nor  gouty,  but  "  interme- 
diate between  the  two,"  presenting  some  characters  of  both,  and 
therefore  well-named  rheumatic  gout. 

4.  That  there  is  an  arthritic  diathesis,  or  peculiar  condition  of 
tissue-health,  involving  tendency  to  inflammation  of  joints  and 
fibrous  structures ;  and  that  upon  this  as  a  foundation  may  be 
built  up,  under  the  influence  of  special  causes,  a  tendency  to  gout, 
rheumatism,  or  any  one  of  their  various  modifications  and  com- 
binations. 


GOUT    AND    CHRONIC    RHEUMATIC    ARTHRITIS.  141 

That  rheumatoid  arthritis  is  to  be  included  under  the  term 
rheumatism.  That  rheumatism  is  an  almost  universally  spread 
tendency  to  arthritis  in  connection  with  catarrhal  nerve-disturb- 
ances, and  gout  is  a  tendency  to  arthritis  in  connection  with  blood- 
disorder.  That  these  two  classes  of  causal  influence  are  not  anta- 
gonistic, but  are,  on  the  contrary,  often  met  with  mixed  together, 
and  that  thus  the  term  "  rheumatic  gout  "  is  completely  justified. 
Further,  that  most  cases  of  this  disease  seen  in  practice  represent, 
not  a  simple  mixture  of  these  two  causal  influences,  but  the 
modified  result  of  such  in  former,  perhaps  in  many,  preceding 
generations.  Hence,  the  inseparable  blending  of  the  two  often 
witnessed. 

5.  That  the  disease  is  of  nervous  origin,  and  due  to  irritation 
of  nerve-centres. 

6.  That  it  is  neither  of  rheumatic,  gouty,  scrofulous,  nor  in 
any  way  of  specific  origin,  but  "is  a  lesion  common  to  several 
kinds  of  ailment,"  and  "  not  justly  separable  as  a  disease  of  in- 
dependent character."  It  is,  according  to  this  view,  always 
symptomatic.1 

I  now  proceed  to  a  critical  review  of  the  several  opinions 
which  I  have  enumerated,  and  address  myself  to  each  as  concisely 
as  possible. 

1 .  Is  it,  or  is  it  not,  the  case  that  rheumatoid  arthritis  is  nothing 
else  than  a  form  of  chronic  rheumatism  ?  I  confess  to  some 
dislike  of  the  latter  term.  It  has  been,  and  still  is,  a  much- 
abused  one,  too  often  a  cloak  for  ignorance,  and  used  without 
exactitude  for  many  different  conditions.  It  is  too  vague.  It 
implies  at  once  an  origin  of  unequivocal  rheumatic  nature,  and 
fairly  presupposes  an  acute  attack  as  a  necessary  antecedent  in 
the  case.  In  this  sense  alone  I  would  retain  the  term,  and  only 
apply  it  to  cases,  not  perhaps  very  common,  in  which  the  joints 
have  not  recovered  after  rheumatic  fever,  and  show  a  tendency 
to  enlargement  and  thickening.  It  is  probablej  I  believe,  that 
some  of  these  cases  pass  on  to  become  indistinguishable  from 
rheumatoid  arthritis,  and,  thus,  the  difference  is  reduced  to  a 
question  of  terms  for  this  minority.  There  should  be  no  insu- 
perable difficulty  in  ascertaining  whether  rheumatic  fever  is  an 
antecedent  of  rheumatoid  arthritis  ;  but  a  practical  inquiry  on 
this  point  I  find  very  difficult.  It  is  easy  to  elicit  a  history  that 
will  suffice  to  satisfy  superficial  inquiry,  but  the  answer  thus 
obtained  is  far  removed  from  the  position  of  a  medical  fact.  Thus, 
it  is  common  to  get  a  history  of  an  acute  attack  which  lasted 

1  The  miasmatic  theory  of  rheumatism  has  not  been  applied  to  this  disease. 


142       RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

weeks  or  months,  which  happened  either  decades  of  years  pre- 
viously, or  only  just  before  the  obvious  symptoms  of  rheumatoid 
arthritis  began.  Stress  is  laid  upon  the  occurrence  of  migratory 
pain  and  sweating  as  leading  and  confirmatory  symptoms,  but 
these  are  not  really  trustworthy  in  most  cases.  Of  far  greater 
importance  is  the  fact,  admitting  of  no  doubt,  of  cardiac  damage 
in  any  case.  This  may  fairly  be  taken  as  unequivocal  evidence 
of  previous  rheumatic  fever,  and  it  is  met  with  in  a  small  per- 
centage of  cases.  This  being  so,  we  may  confidently  affirm  that 
these  patients  are  of  rheumatic  habit.  But  how  is  the  argument 
for  the  proposition  that  "  rheumatoid  arthritis  is  evolved  out  of 
acute  rheumatism  "  affected  by  the  results  of  careful  inquiry  into 
this  point  ?  Most  materially,  _  as  I  think,  and  in  a  sense  contrary 
to  that  view.  It  is  not  often  that  the  joints  are  examined  in  the 
bodies  of  those  who  have  suffered  from  rheumatic  fever.  For 
some  years  past,  however,  my  colleague,  Dr.  Norman  Moore,  our 
Lecturer  on  Morbid  Anatomy,  has  habitually  made  this  exami- 
nation, and  he  informs  me  that  he  can  find  no  evidence  of  any 
kind  to  indicate  the  previous  influence  of  rheumatic  fever  on  the 
joints.  The  rule  is,  that  the  process  subsides  entirely,  leaving 
all  the  articular  structures  in  a  natural  condition.  The  cardiac 
damage,  if  any,  remains  ;  the  joint-mischief  is,  as  a  rule,  tem- 
porary, and  passes  off  completely. 

As  Dr.  Moore  examines  the  joints  in  nearly  every  post-mortem 
investigation  which  he  makes,  his  evidence  is  obviously  of  the 
greatest  value.  Judging  by  the  light  of  these  facts — namely,  the 
extreme  difficulty  of  securing  trustworthy  history  of  past  acute  rheu- 
matism, and  the  absence  of  joint-mischief  in  cases  that  have  suffered 
from  it  unequivocally — we  are  in  a  position  to  affirm  that  the 
opinions  of  those  who  believe  rheumatoid  arthritis  to  be  an  evolu- 
tion of  rheumatic  fever  in  many  instances  is  erroneous.  The  most 
that  can  rightly  be  said  is  that,  in  a  small  proportion  of  the  cases, 
there  is  evidence  of  past  rheumatic  fever.  As  I  shall  show  later 
on,  this  evidence  is  not  without  value,  and  aids  us  in  a  proper 
conception  of  the  malady  in  question.  It  is  probable  that  the 
illness  so  often  described  as  rheumatic  fever  is  an  acute  beginning 
of  the  disease  now  well-advanced.  I  could  array  a  list  of  eminent 
authorities  in  support  of  this  first  proposition,  and  of  others  who 
regard  it,  with  myself,  as  only  occasionally  true. 

If  the  foregoing  view  be  held,  on  the  understanding  that  rheu- 
matic fever,  as  a  rule,  is  but  a  rare  antecedent  in  the  disease,  I 
have  otherwise  not  much  objection  to  offer  to  it.  I  consider, 
however,  that  the  term  chronic  rheumatism  insufficiently  expresses 


GOUT    AND    CHRONIC    RHEUMATIC   ARTHRITIS.  1 43 

all  the  peculiarities  of  this  disease,  and  I  would  rather  call  it  a 
form  of  chronic  rheumatism,  since  the  true  nosological  relation  of 
the  disorder  is  thus  expressed.  Still  I  think  a  better  definitive 
term  may  be  found. 

2.  The  second  view  is,  that  rheumatoid  arthritis  has  no  direct 
relation  to  rheumatism,  but  merely  resembles  it  in  some  points  ; 
that  it  has  no  relation  to  gout,  may  exist  with  or  without  any 
rheumatic  or  gouty  tendency,  and  is  not  antagonistic  to  either, 
partaking  rather  of  the  nature  of  a  senile  change,  and  induced 
by  wear  and  tear  of  joints.  I  cannot  accept  this  doctrine.  I 
have  already  adduced  some  evidence  of  a  relation  to  true  rheu- 
matism, though,  it  is  true,  this  relation  is  not  proved  to  be  direct, 
save  in  a  few  instances.  The  resemblance,  then,  can  only  be  in 
respect  of  the  arthritic  affection ;  but  I  have  shown  that,  beyond 
the  fact  of  inflammation,  in  the  one  case  acute  and  temporary, 
and  in  the  other  chronic  and  persistent  for  the  most  part,  with 
acute  phases,  there  is  nothing  in  common  between  the  two  con- 
ditions. Hence,  I  admit  this  view,  which  has  been  very  ably 
set  forth  by  so  careful  a  thinker  and  observer  as  Dr.  Pye-Smith, 
only  in  respect  of  its  recognition  of  this  disorder  as  a  distinct 
one,  and  not  in  direct  relation  to  either  rheumatism  or  gout. 

That  it  exists  without  any  rheumatic  or  gouty  predisposition 
or  tendency,  I  dispute.  If  by  this  is  signified  that  the  ordinary 
characters  of  acute  rheumatism,  or  of  true  gout,  are  not  present 
in  the  ordinary  forms  of  the  disease,  I  assent ;  as  I  do,  also, 
to  the  further  statement  that  rheumatoid  arthritis  is  not  antago- 
nistic to  the  occurrence  of  true  rheumatism  or  of  true  gout. 
That  the  specific  changes  induced  by  the  disease  have  the  char- 
acters of  senile  degenerations  in  joints  is  a  fair  proposition, 
but  a  proper  conception  of  the  whole  disorder  includes  the  arti- 
cular disorganizations  known  as  malum  senile  and  single-joint 
rheumatism ;  and  many  premature  textural  degenerations  in  the 
body  may  be  termed  senile — to  wit,  atheroma  in  a  child's  artery. 
From  this  point  of  view  we  get  no  light  in  the  inquiry.  We 
must  make  larger  and  deeper  generalizations. 

3 .  We  come  next  to  the  third  view,  that  the  disease  is  neither 
rheumatic  nor  gouty,  but  occupies  an  intermediate  place  between 
the  two.  I  quote  now  the  late  Dr.  Fuller's  well-known  opinion. 
Dr.  Fuller  employed  the  term  "  hybrid  "  in  the  first  edition  of  his 
book,  but  omitted  it  subsequently.  It  was  incumbent  on  him  to 
do  so,  for  a  malady  could  not  be  a  hybrid  which,  according  to 
him,  was  "not  a  compound  of  the  two  diseases"  in  question.1 
1  Fuller,  On  Rheumatism,  &c,  3rd  edit.,  i860,  p.  331. 


144      -RELATION    OF    GOUT   TO    OTHER    MORBID    STATES. 

For  Dr.  Fuller,  rheumatoid  arthritis  was  something  "  essentially 
distinct  from  both,"  "  closely  allied  to  rheumatism  while  present- 
ing some  of  the  features  of  gout."  Although  denying  that  the 
disease  had  "  any  sort  of  connection  with  rheumatism,"  Dr.  Fuller 
declared  that  he  "  had  repeatedly  known  patients  crippled  by 
rheumatic  gout,  which  commenced,  in  the  first  instance,  as  a 
sequel  of  acute  rheumatism."  Surely,  this  was  a  contradiction. 
The  experience  of  most  observers  coincides  with  that  of  Dr.  Fuller, 
but  their  deduction  is  different  from  his.  Sir  Alfred  Garrod 
allows  that  this  sequel  occasionally  happens,  but  guards  himself 
by  adding,  that  error  may  arise  from  mistaking  the  acute  stage 
of  the  disease  for  true  rheumatic  fever.  So  far  as  I  know,  only 
two  authorities  give  their  experience  from,  the  other  side.  Thus, 
Sir  Benjamin  Brodie  declared  that  in  most  of  the  cases  occurring 
in  the  affluent  classes  the  disease  seemed  to  be  of  gouty  origin ; 
and  Dr.  Fuller  believed  that  rheumatic  gout  might  arise  in 
persons  who  had  been  or  might  become  truly  gouty,  but  that 
there  was  no  connection  with  either  disease.  To  justify  the 
term  "  rheumatic  gout,"  I  think  proof  is  required  that  rheumatoid 
arthritis  may  be  set  up  as  well  by  gout  as  by  rheumatism.  I 
do  not  deny  the  possibility  of  this,  but  I  can  nowhere  find  proof  of 
it.  I  believe,  with  Garrod,  that  most  of  Sir  Benjamin  Brodie's  cases 
were  truly  gouty  in  their  nature,  and  not  unequivocal  instances 
of  rheumatoid  arthritis.  Dr.  Fuller  believed  also  in  the  existence 
of  a  specific  poison  as  the  agency  of  this  disease,  distinct  from, 
though  allied  to,  that  of  rheumatism  and  gout.  He  further 
described  cases  in  which  lithates  of  soda  and  lime  were  deposited 
on  the  cartilages,  as  instances  of  rheumatic  gout  in  which  the 
symptoms  had  been  gouty  during  life. 

To  sum  up  :  Dr.  Fuller  believed  that  rheumatoid  arthritis  was  a 
specific  disease,  and  that  it  might  coalesce  with  rheumatism  or  with 
gout.  He  strongly  insisted  on  the  aptness  of  the  term  "  rheumatic 
gout,"  remarking  that  "the  titles  of  diseases  are  seldom  used  to 
indicate  their  pathology,  but  rather  as  a  means  of  establishing 
their  identity."  We  may  hope  for  better  things  at  the  present 
day  in  this  respect,  and  our  effort  is  plainly  to  discover  first  what 
is  true,  and  then  to  apply  the  best  name  we  can  find  to  express 
the  knowledge  we  have  acquired.  The  reason  for  my  objection  to 
this  term  will  appear  in  discussing  the  next  proposition. 

4.  The  fourth  view  is  that  which  has  been  set  forth  by  Mr. 
Hutchinson,  who  indicates  the  use  of  the  term  "  rheumatic  gout " 
as  exactly  expresssing  the  nosological  position  of  the  disease  in 
question.      For  him  the  whole  matter  is  extremely  simple.      He 


OBJECTIONS    TO    MR.    HUTCHINSON  S    VIEWS.  1 45 

affirms  that  rheumatism  and  gout  may  mix  in  any  proportions, 
as  may  spirits  and  water,  and  that  the  common  malady,  rheuma- 
toid arthritis,  is  in  most  cases  actually  such  a  mixture.  I  can- 
not accept  this  teaching,  and  regret  to  join  issue  here  with  one 
for  whose  genius  and  clinical  powers  I  have  the  deepest  venera- 
tion. In  combating  this  view,  I  take  first  as  illustrations  of  the 
disease  cases  occurring  in  Ireland,  Scotland,  Holland,  or  indeed 
anywhere  but  in  England  proper,  and  I  ask,  Where  is  the  gouty 
element  or  factor  forthcoming  in  such  patients  ?  Gout  is  all 
but  unknown  in  these  countries,  and  the  deduction  necessarily 
follows,  that  here,  at  any  rate,  there  can  be  no  mixture  of  the 
two  diseases.  Mr.  Hutchinson's  reply  to  this  objection  is,  I  be- 
lieve, that  we  have  no  right  to  affirm  that  uratic  deposit  is  the 
only  significant  token  of  unequivocal  gout.  This  is,  however, 
the  doctrine  of  the  schools.  When  such  deposits  exist,  we  have 
unmistakable  evidence  of  true  gout.  Now,  in  the  majority  of 
cases  of  pure  gout  this  evidence  is  only  forthcoming  in  the  dead- 
house.  The  researches  of  Dr.  Moore  prove  that  they  are  often 
present  when  unsuspected,  and  that  only  very  careful  search  will 
sometimes  find  them.  No  outward  token  of  arthritis  is  present 
in  many  cases  ;  certainly  no  indications  of  rheumatoid  arthritis 
are  found,  as  a  rule,  in  such  instances. 

If  it  is  declared  that  uratic  deposit  is  no  longer  the  criterion  of 
true  gouty  disease,  we  are  placed  at  once  in  a  difficulty.  For  my 
part,  I  think  we  are  not  at  present  in  a  position  to  affirm  more 
than  this,  that,  in  a  given  case  of  gout  we  may  find  uratic  deposit 
in  certain  joints  and  parts,  and  evidence  of  more  or  less  arthritis, 
such  as  erosion  of  cartilage  and  everted  articular  edges,  in  other 
joints.1  I  am  quite  convinced  that  uratic  deposit  is  not  the  sole 
token  of  gouty  arthritis,  for  I  recognize  ulceration  of  articular 
cartilage  as  almost  equally  significant  in  the  same  joint,  or  in 
others,  without  deposit.  But  I  also  maintain  that  gouty  arthritis, 
which,  be  it  remembered,  is  only  one  of  the  manifestations  of 
gouty  disease,  never  produces  all  the  specific  lesions  of  rheuma- 
toid arthritis.2 

It  may  sometimes  closely  simulate  them  during  life,  and 
render  the  diagnosis  difficult,  and  at  times  impossible.  Thus, 
there    may    be    every    external    sign    commonly    recognized    as 

1  Bristowe,  Theory  and  Practice  of  Medicine,  chapter,  "Gout."  W.  G-airdner 
declared  that  he  had  seen  many  cases  where  urate  of  soda  did  not  remain  as  enduring 
evidence  of  each  attack  of  gout  ;  but  as  no  post-mortem  evidence  is  given,  no  value 
attaches  to  this  statement. 

2  Virchow  has  expressed  the  opinion  that  the  one  has  no  connection  with  the 
other.    (On  Nephritis  Arthritica,  Berliner  Jdinisehe  Wochenschrift,  1884.  No.  I.) 

K 


146   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

peculiar  to  rheumatoid  arthritis  :  knotty  and  dislocated  joints, 
with  and  without  effusion,  crackling,  eversion  of  fingers  to  ulnar 
side  ;  and  not  only  the  signs,  but  the  symptoms  of  rheumatoid 
arthritis.  Such  patients  as  have  suffered  both  from  gout  and 
rheumatism  can,  however,  usually  tell  of  a  difference  in  the 
respective  pains  and  symptoms  of  each.  I  have  met  with  such 
patients,  and  Scudamore  gives  particulars  of  one.1  I  believe 
firmly  that  cases  of  true  gouty  arthritis  are  frequently  mistaken 
for  rheumatoid  arthritis,  and  Dr.  Fuller's  later  experience  led 
him  to  a  similar  opinion.2 

The  converse  error  is,  perhaps,  less  frequently  fallen  into. 
Hence,  for  a  correct  determination  in  any  case,  that  clinical 
acumen  which  Mr.  Hutchinson  so  much  deprecates,  and  which 
he  thinks  only  leads  us  into  error,  must  be  applied.  Until  we 
have  more  knowledge,  we  must  hold  by  certain  symptoms  and 
signs.  Gout  must  signify  the  presence  of  uratic  deposit  some- 
where in  the  body — I  do  not  say  necessarily  or  only  in  the 
joints, — or  excess  of  uric  acid  in  the  blood  ;  rheumatoid  arthritis 
must  signify  destruction  of  synovial  membrane  and  cartilage, 
ulceration  of  bone,  eburnation,  and  osteitis ;  and  acute  rheu- 
matism must  be  held  to  do  no  permanent  damage  to  joints 
affected  by  it.  I  referred  just  now  to  Heberden's  nodes  as  a 
form  of  rheumatoid  arthritis.  I  have  met  with  them  in  cases 
of  pure  gout.  On  dissection,  I  have  found  no  uratic  deposit 
in  the  joints,  but  only  a  small  quantity  in  the  investing  liga- 
ments. There  was  no  appearance  of  tophi.  The  phalangeal 
tubercles  were  enlarged  exactly  as  in  cases  of  rheumatoid 
arthritis.  The  gouty  nature,  suspected  only  during  life,  was 
made  certain  after  death,  and  hence  I  cannot  accept  Heberden's 
dictum  that  they  are  never  gouty.3  Clinical  study  of  gouty  and 
other  forms  of  arthritis,  carried  on  with  an  open  mind,  has  con- 
vinced me  that  gouty  disease  will  often  simulate  some  forms  and 
phases  of  rheumatoid  arthritis,  and  I  do  not  require  to  invoke  any 

1  This  case  is  very  important,  and  worth  quoting.  A  man,  aged  thirty,  had  two 
attacks  of  rheumatic  inflammation  of  ankle-joints,  with  flying  pains  in  different  parts 
of  the  body.  Two  months  afterwards,  being  in  improved  circumstances,  and  having 
lived  indulgently,  gout  came  in  one  great  toe  and  instep,  with  shiny  skin  and  swelling, 
deep  red,  then  purple  colour,  and  finally  desquamation.  No  intermission  in  the  pain 
was  experienced  in  the  rheumatic  attack  ;  but  in  the  gout  the  worst  pain  was  felt 
from  twelve  to  three  A.M.,  and  about  five  he  procured  sleep.  The  character  of  the 
pain  differed  in  the  two  disorders.  The  man's  father  was  gouty ;  his  only  sister 
suffered  severely  from  chronic  rheumatism.      Op.  cit.,  p.  168,  3rd  edit.,  1819. 

2  Op.  cit,  p.  44. 

3  "  Nihil  certe  illis  commune  est  cum  arthritide,  quoniam  in  multis  reperiuntur, 
quibus  morbus  ille  est  incognitus." — Commentarii,  De  Nodis  Digitorum. 


COALESCENCE    OF    GOUT    AND    RHEUMATISM.  1 47 

element  of  the  latter  malady  to  explain  all  the  phenomena.  I  am 
aided  in  my  diagnosis  by  other  clinical  considerations.  The  dead- 
house  is  not  my  only  appeal,  for  it  can  only  tell  me  a  part  of  the 
whole  story.  In  any  given  case,  Mr.  Hutchinson  would  say,  All 
that  is  not  obviously  gouty  is  rheumatic.  He  remarks  also  that  it 
is  very  difficult  to  say  how  far  rheumatism  pure  can  go.  I  would 
add,  and  equally  difficult  to  say  how  far  pure  gout  can  go.  This 
difficulty  as  to  the  gouty  element  has  never  much  troubled  clinical 
inquirers  out  of  England.  This  is  surely  a  significant  fact,  and 
I  might  add,  further,  that  it  has  never  much  exercised  clinical 
inquirers  outside  London.  Now,  London  is  the  head-centre  of 
gouty  disease,  and  there  is,  probably,  more  gout  and  goutiness 
in  London  than  in  any  other  spot  on  the  globe.  Hence,  our 
peculiar  difficulties  and  perplexities  in  eliminating  its  influence 
in  the  arthritic  affections  we  have  to  deal  with.  It  affects  our 
poor  as  much  as  our  affluent  classes.  Scottish,  Irish,  and  foreign 
immigrants  come  to  London  presumably  innocent  of  all  gouty  taint, 
and  grow  gouty  in  the  great  metropolis.  This  is  unquestionable, 
and  in  these  persons  we  can  show  cases  of  unequivocal  uratic  gout, 
which  we  may  firmly  believe  would  never  have  developed  in  their 
original  countries.  London  life  and  habits  have  to  answer  for  this, 
be  they  what  they  may.  The  result  of  this  has  been  to  complicate 
cases  of  rheumatoid  arthritis,  and  to  lead  many  observers  in  Eng- 
land into  errors  which  have  not  misled  observers  elsewhere. 

Can  there,  then,  be  a  mixture  or  coalescence  of  gout  and  rheu- 
matic disease  ?  I  reply,  Yes.  It  would  be  very  remarkable  if 
there  were  not.  Such  a  mixture,  a  veritable  hybrid,  does  occur. 
Clinical  observation  and  post-mortem  search  prove  this.  Museum 
specimens,  not  many  in  number,  however,  attest  the  fact.1  Gout 
may  supervene  on  rheumatoid  arthritis,  and  rheumatoid  arthritis 
may  come  on  in  a  gouty  subject,  and  plain  tokens  of  both  will  be 
manifested.  There  is  no  antagonism,  as  most  good  observers  have 
remarked. 

Mr.  Hutchinson  appeals  to  the  experience  gained  in  those 
stores  of  clinical  information,  the  London  Workhouse  Infirmaries, 
an  experience  which  has  convinced  him  of  the  co-existence  of 
rheumatic  and  gouty  disease.  I  have  also  availed  myself  of  this 
experience  ;  but  I  read  the  story  differently,  and  would  venture 
the  opinion  that  even  in  London  practice  it  is  possible  to  make 
exact  diagnosis  in  the  majority  of  these  cases.  I  feel  sure  that 
the  frequent  occurrence   of  various  forms  of   gouty  arthritis   in 

1  Dr.  Adams  records  only  one  instance  in  his  experience.     The  preparation  is  in 
the  Museum  of  Trinity  College,  Dublin.     Op.  cit.,  p.  309. 


I48       RELATION    OF    GOUT    TO    OTHER    MORBID    STATES. 

London  lias  led  to  error,  and  to  the  inclusion  of  purely  gouty- 
cases  in  the  category  of  rheumatoid  arthritis.  I  do  not  agree 
with  Mr.  Hutchinson  that  it  is  proper  to  call  all  that  is  not 
plainly  gouty,  rheumatic. 

Gouty  arthritis  will  produce  lips  on  the  ends  of  bones,  crack- 
ling, chronic  synovitis,  and  other  features  commonly — but  erro- 
neously, as  I  believe — supposed  to  be  alone  significant  of  rheu- 
matic disease.  As  I  have  already  remarked,  observers  in  Dublin 
and  elsewhere  have  fewer  of  these  difficulties.  These  peculiar  per- 
plexities are  rather  of  English  origin,  and,  without  doubt,  more 
cases  of  rheumatic  and  gouty  coalescence  are  met  with  here. 

I  am  entirely  in  accordance  with  Mr.  Hutchinson's  views  as  to 
the  basic,  so-called  arthritic,  diathesis  on  which  these  two  mala- 
dies rest.  And  with  respect  to  the  modifications  induced  by  the 
comminglings  of  these  states,  or  of  other  diatheses,  such  as  the 
strumous,  all  of  which  must  be  taken  into  consideration  of  a 
large  question  such  as  this,  I  am  also  in  accord  with  Hutchinson, 
and  think  his  view  most  suggestive  and  philosophical.  The 
teaching  of  Laycock  and  of  Paget  on  this  point  has  never  yet  had 
its  full  recognition. 

It  must  be  remembered,  however,  that  a  trustworthy  ancestral 
history  of  either  rheumatism  or  gout  is  most  difficult  to  secure, 
and  often  fallacious  in  all  classes  of  patients,  and  especially  in  the 
lower  orders.  It  seems  certain,  as  Paget  has  shown,  that  latent 
tendencies  often  exist.  Death  may  supervene  before  they  are 
manifested,  or  they  may  only  come  out  very  late  in  life.  The 
offspring  will  inherit  the  parental  or  ancestral  tendency,  and  may 
develop  it  early.  Or,  again,  far  distant  ancestral  tendency  may 
only  come  out  in  later  generations. 

Mr.  Hutchinson  affirms  that  so  loug  as  an  arthritic  person 
has  sound  digestion  and  healthy  kidneys,  his  rheumatic  manifes- 
tations will  be  free  from  gout ;  but  once  let  him  fail  in  these 
respects,  and  it  is  scarcely  possible  for  him  to  have  a  rheu- 
matic inflammation  which  is  not  modified  and  made  gouty  by  the 
previously  existing  peculiarity  of  his  blood.  My  belief  is,  that 
many  of  these  cases  continue  free  from  gouty  development  in  spite 
of  failing  renal  and  digestive  organs,  and  that  gout  is  not  always, 
or  often,  waiting  on  rheumatism. 

Heberden  remarks,  "  It  must  be  owned  that  there  are  cases  in 
which  the  criteria  of  both  are  so  blended  together  that  it  is  not 
easy  to  determine  whether  the  pains  be  gout  or  rheumatism ; " 
and  again,  "  These  two  distempers,  though  of  the  same  family," 
&c.  ("  hos  morbos,  cognatos  sane,"  op.  cit.). 


SPINAL    ARTHROPATHIES.  149 

With  respect  to  the  humoral  theory  of  rheumatoid  arthritis,  I 
think  we  have  as  yet  no  evidence  of  the  hypothetical  specific 
poison  conceived  by  Dr.  Todd  and  Dr.  Fuller  as  the  causative 
agent  in  this  malady.  So  far  as  we  have  gone,  we  have  esta- 
blished a  place  for  rheumatoid  arthritis  outside  rheumatic  mani- 
festations, and  outside  gouty  disease.  Is  it  possible  to  correlate 
the  three  diseases  ?  I  believe  it  is,  and  in  doing  so  I  must  bring 
forward  more  of  the  teaching  of  Mr.  Hutchinson  and  others 
respecting  these  disorders  in  general.  Before  proceeding  to  this, 
however,  I  must  discuss  the  fifth  view  which  is  held. 

5.  The  fifth  view,  that  the  disease  is  of  nervous  origin,  is  the 
latest  that  has  been  presented.  Mr.  Hutchinson's  opinion  that 
rheumatism  is  a  catarrhal  neurosis,  or  reflex  nervous  inflammation, 
leads  up  to  the  stronger  expression  of  neurotic  origin  here  laid 
down.  The  evidence  for  this  is  based  upon  the  fact  that  joint- 
disease  has  been  observed  to  follow  upon  lesions  of  the  spinal 
chord.  Thus  effusions  and  painful  arthritis  have  been  noticed  in 
cases  of  hemiplegia  with  descending  degeneration  in  the  chord, 
and  a  well-marked  form  of  arthritis  has  been  recognized  in  connec- 
tion with  tabes  dorsalis,  sometimes  described  as  Charcot's  disease.1 

Sceptics  in  medicine,  who,  by  the  way,  seldom  advance  any 
theories  or  suggestions  of  their  own,  may  scoff,  if  they  please,  at 
the  attempt  to  connect  the  two  conditions  last-mentioned,  or 
decline  to  make  up  their  minds  while  opinions  oscillate  between 
humoral  and  neuro-trophic  theories  of  rheumatoid  arthritis  ;  but  I 
think  it  is  proved  to  the  conviction  of  most  impartial  clinical 
observers,  certainly  amongst  physicians,  that  there  is  a  form 
of  degenerative  arthritis  associated  with  tabes  dorsalis.  This 
is  not  the  place  to  adduce  all  the  arguments  in  favour  of 
the  specific  connection,  and  I  shall  do  no  more  than  meet 
with  a  denial  the  assertion  that  the  joint-disease  of  tabes  dor- 
salis is  commonly  due  to  local  injury.  I  am  firmly  convinced 
of  the  existence  of  the  disease  as  a  special  form  of  arthritis,  and 
I  would  ask  whether  it  was  in  any  degree  likely  that  the  man 
who  did  some  of  the  best  clinical  work  on  the  subject  of  rheu- 
matic and  gouty  arthritis  five-and-twenty  years  ago,  would  at  a 
later  period  fall  into  error  on  a  matter  of  observation  forced  upon 
him  by  larger  and  more  special  experience.  It  is  noteworthy 
that  surgeons  have  mostly  refused  credence  to  Charcot's  views. 
This  is  perhaps  not  unnatural.  Here,  however,  I  am  only  con- 
cerned  to   note   that   the  characters   of   spinal    arthropathy    are 

1    Vide  Art.  by  myself  on  "  Charcot's  Disease,"  Heath's  Dictionary  of  Practical 
Surgery,  vol.  i.  p.  272. 


150      RELATION    OF   GOUT    TO    OTHER    MORBID    STATES. 

clinically  different  from  those  of  ordinary  rheumatoid  arthritis, 
and  that  the  main  differences  consist  in  the  sudden  onset  of  the 
disease,  the  extreme  effusion  into  the  joint  affected — a  symptom 
which  has  "been  erroneously  denied  as  common  in  rheumatoid 
arthritis — the  rapid  absorption  of  the  ends  of  the  joints,  and  the 
remarkable  fragility  of  the  bones. 

The  trophic  changes  run  riot,  so  to  speak,  and  such  alterations 
as  these  seem  to  point  plainly  both  to  different  setiology  and 
progress. 

Opponents  of  the  view  that  there  is  any  relation  between  the 
spinal  lesion  and  the  joint-changes,  conceive  that  there  is  nothing 
remarkable  in  the  onset  of  ordinary  rheumatoid  disease  in  a 
certain  proportion  of  cases  of  tabes  dorsalis. 

Those  who  adhere  to  the  view  that  rheumatoid  arthritis  is  a 
tropho-neurosis  refer  to  its  frequent  onset  after  nervous  shock, 
depression,  and  grief ;  and  the  possibility  of  direct  injury  to 
nerve-roots  by  the  mechanical  changes  induced  by  spondylitis 
is  also  conceived.  For  my  part,  while  fully  recognizing  tabetic 
arthropathy  as  a  spinal  lesion,  I  do  not  find  evidence  to  warrant 
so  large  a  deduction  as  that  the  disease  which  we  know  as  rheuma- 
toid arthritis  owns  thus  directly,  and  always,  a  similar,  or  even 
kindred,  lesion.  Many  features  of  the  common  form  of  the 
disease  are  perhaps  best  explained  on  a  nervous  basis,  and 
these  will  be  better  taken  note  of  in  discussing  the  sixth  and 
last  view. 

Not  to  do  more  than  allude  to  the  fact  that  in  Charcot's 
disease  it  is  commonly  a  large  joint,  such  as  the  knee,  shoulder, 
or  elbow,  which  is  affected,  I  may  mention  that  in  these  cases 
we  do  not  readily  find  the  special  diathetic  characters  proper  to 
the  rheumatic  habit  impressed  upon  these  subjects,  and  for  me 
this  is  a  matter  of  much  significance.  I  do  not  think  there  is 
any  evidence  to  support  the  view  that  Charcot's  disease  is  a  new 
manifestation.  I  imagine  that  it  had  been  previously  overlooked, 
and  that  the  specific  relations  of  the  disorder  had  not  been  recog- 
nized. 

6.  According  to  the  sixth  view,  rheumatoid  arthritis  is  neither  of 
rheumatic,  gouty,  scrofulous,  nor  of  any  specific  origin,  and  not 
justly  separable  as  an  independent  disease,  but  is  a  lesion  common 
to  several  kinds  of  ailment.  This  is  the  view  of  Dr.  Ord,  who 
has  endeavoured  to  show  that  this  disease  is  the  result  of  a  lesion 
of  the  spinal  chord  set  up  by  peripheral  irritation  of  various 
forms  and  degrees,  and  that  a  condition  of  exalted  susceptibility 
and  reflex  activity  of  the  chord  must  enter  into  our  conception  of 


DR.  ORD  S  VIEWS  ON  CHRONIC  RHEUMATIC  ARTHRITIS.     I  5  I 

it.1  Denying  the  humoral  theory,  he  proposes  a  neurotic  one, 
and  contends  that  we  meet  with  the  disease  as  a  result  of  primary 
lesion  in  the  chord,  and  as  also  resulting  from  such  varied  irrita- 
tions as  gonorrhoea,  simple  urethritis,  ovario-uterine  troubles,  trau- 
matism, acute  rheumatism,  chronic  gout,  and  foreign  growths 
in  joints.  He  proposes  to  discard  the  temi  rheumatoid,  and  to 
apply  in  each  case  such  an  one  as  will  express  the  form  of  the 
exciting  cause,  such  as  traumatic,  blenorrhagic,  urethral,  rheu- 
matic, hystero-  and  myelo-arthritis.  He  believes,  further,  that 
the  disease  may  spread  from  joint  to  joint  symmetrically  by 
reflex  nervous  influence.  This  view  is  very  philosophical,  and 
constitutes  a  distinct  advance  in  our  conception  of  the  disease. 
It  appears  sufficiently  comprehensive,  and  it  is  not  easy  to  contro- 
vert. My  chief  objection  to  it  lies  in  this,  that  too  little  regard 
is  paid  to  the  inherent,  and  often  latent,  tendency  to  some  form 
of  arthritic  disturbance  in  certain  persons.  If  there  is  not  some- 
thing special  about  the  individual,  these  alleged  sources  of  peri- 
pheral irritation,  which  are  sufficiently  common,  should  surely 
affect  indifferently  all  persons  exposed  to  them ;  but  this  is  not 
the  case.  The  specific  changes  of  rheumatoid  arthritis  are  only 
induced  in  the  diathetically-predisposed  of  the  community. 

There  is  an  inherited  something,  or  a  superinduced  something, 
which  favours  the  particular  evolution  in  the  particular  person. 
It  is  this  specific  vulnerability  which,  in  my  view  of  the  matter, 
marks  off  the  individual  for  an  onset  of  arthritic  trouble — just  as 
much  so,  indeed,  as  does  the  special  vulnerability  of  a  person  of 
strumous  or  tubercular  tendency  lay  him  open  to  the  onset  of 
active  strumous  or  tuberculous  trouble,  when  specially  exposed. 
Hence,  I  join  issue  with  Dr.  Ord  in  discarding  the  term  rheumatic, 
or  rheumatoid,  in  this  disease — holding,  as  I  do,  that  these  mani- 
festations are  implanted  on  persons  with  specially  impressed  vital 
tendency.  I  do  not  believe  that  the  rheumatic  diathesis  is 
universal,  as  has  been  alleged.  Some  persons  will  never  develop 
rheumatism  in  any  form,  however  much  exposed  to  exciting  causes. 

I  can  therefore  conceive  an  imaginary  person,  of  perfect  health 
and  constitution,  upon  whom  no  one  of  the  indicated  peripheral 
irritations  shall  reflexly  set  up  such  changes  as  we  recognize  in 
rheumatoid  arthritis. 

I  think  the  evidence  is  strongly  in  favour  of  Dr.  Ord's  view, 
that  extension  of  the  disease  and  symmetrical  implication  of 
joints  are  often  of  a  truly  reflex  character  ;  and  if  this  be  a  true 
explanation,  it  favours  a  neuro-trophic  theory  of  the  disease. 

1  British  Medical  Journal,  January  31,  1S80,  p.  155. 


152   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

Amongst  less  well-recognized  causes  leading  to  these  changes 
are  chronic  dysentery,  and  arterio-capillary  fibrosis  with  contracted 
kidney,  the  latter  connection  having  been  pointed  out  by  Lan- 
cereaux,  but  this  has  not  yet  been  observed,  perhaps  because  not 
looked  for,  in  this  country.1 

And  now  to  sum  up. — To  what  view  of  the  nosological  rela- 
tions of  this  disease  are  we  led  by  a  consideration  of  its  characters  ? 
I  find  that  some  of  the  best  thinkers  confess  themselves  baffled 
for  the  present  in  the  attempt  to  settle  the  question.  Much  as  I 
could  wish  to  lay  down  a  theory  that  would  command  universal 
acceptance,  I  fear  I  can  do  no  more  than  help  to  clear  the  way 
for  further  observation.  I  think  we  are  only  now  in  a  position 
to  advance  with  more  rapid  and  certain  steps  than  our  prede- 
cessors. We  have  the  advantage  of  an  exact  anatomy,  we  have 
fairly  well-determined  the  characters  special  to  definite  forms  of 
arthritis,  and  we  have  now  to  gather  facts  in  family  and  clinical 
history  which  shall  put  us  on  the  way  to  the  goal  we  seek  to 
reach.  Collective  investigation,  properly  conducted,  will  do  much 
to  help.  Family  life -histories,  accurately  recorded,  will  do  more. 
But  is  this  all  ?  I  think  there  yet  remains  the  modern  study  of 
the  modifications  and  transformations  of  disease,  the  effects  of 
time,  of  locality,  of  habits  of  life.  And  this  large  question  faces 
us  here  as  we  try  to  form  a  true  conception  of  rheumatoid 
arthritis  as  we  meet  with  it  to-day.  We  may  say  that  in  a 
majority  of  cases  we  find  the  same  changes  induced  now  as  were 
met  with  in  ages  past ;  but  it  may  be  that  forms  of  arthritis 
occasionally  come  before  us  which  differ  from  those  observed  by 
our  predecessors,  and  that  forms  long-suppressed  may  again  crop 
up,  as  it  were,  and  be  with  difficulty  relegated  to  their  proper 
place.  And,  so,  disease  in  a  pure  form  may  come  sometimes  to 
be  modified,  and  give  rise  to  varieties  for  which  no  place  is 
readily  found.  It  seems  only  too  likely,  for  example,  that  in 
England  the  coalescence  of  rheumatic  and  gouty  diseases  has 
produced  a  mongrel  type  of  malady  in  many  instances — not  a 
mere  mixture,  but  a  new  type  which  may  propagate  itself,  and 
that,  thus,  may  arise  some  of  our  perplexities.2  Such  propa- 
gation is  not  likely  to  be  enduring.  If  hybrids  do  not  breed, 
mongrels  certainly  may.      There   are,  however,  facts  to  support 

1  Transactions  of  the  International  Medical  Congress,  London,  1881,  vol.  i.  p.  384. 

2  Mr.  Hutchinson  has  directed  attention  to  various  maladies  affiliated  with  what 
he  terms  rheumatic  gout  and  gout,  but  differing  somewhat  from  both,  and  these 
include  various  eye-troubles,  such  as  iritis,  hsemorrhagic  retinitis,  and  some  forms  of 
glaucoma,  lumbago,  sciatica,  chronic  rheumatoid  arthritis,  Heberden's  nodes,  and, 
possibly,  haemophilia. 


GOUT,  A  MANIFESTATION  OF  THU  ARTHRITIC  DIATHESIS.     I  53 

the  belief  that  while  distinct  types  prove  stable  and  enduring, 
mongrel  progeny  is  not  so ;  and  hence  we  may  fairly  conceive 
that  a  strongly-marked  and  distinct  disease  such  as  rheumatoid 
arthritis,  owning  a  much  older  ancestry  than  gout,  will  con- 
stantly tend,  even  amidst  potent  modifying  conditions,  to  revert 
to  its  pure  type.  Still,  we  must  be  prepared  to  meet  in  practice 
with  mongrel  forms  of  disease.  The  immunity  from  chronic  rheu- 
matism enjoyed  by  light-haired  men,  if  it  be  true,  demands 
attention  and  close  study.1  Careful  and  prolonged  clinical 
observation  alone  will  help  us  here. 

It  is  remarkable  that  we  should  still  be  ignorant  of  the  mea- 
sure of  heredity  of  this  disease.  The  difficulty,  of  course,  is  to 
get  trustworthy  family  history,  and  to  go  back  far  enough 
for  this  evidence.  My  own  experience  has  furnished  in  most 
cases  a  clear  history  of  rheumatic  ailments,  or  of  arthritic 
disease,  in  the  ancestry.  I  have  observed,  and  Garrod  and 
others  inform  me  their  experience  is  similar,  that  the  daughters 
of  gouty  men  not  infrequently  become  the  subject  of  rheu- 
matoid arthritis.  What  is  the  proper  explanation  of  this  ?  Is 
this  a  transformation  of  gout  in  the  female,  or  only  a  separate 
manifestation  of  the  arthritic  diathesis  ?  The  latter  view  alone 
commends  itself  to  me,  and,  to  explain  the  fact,  it  would  be 
necessary  to  secure  a  family  history  extending  over  many  gene- 
rations. Until  I  can  secure  this,  I  prefer  to  accept  the  theory 
of  a  basic  arthritic  diathesis,  which  explains  a  relationship,  though 
indirect,  between  the  two  disorders.  The  facts  elicited  by  study 
of  the  heredity  of  rheumatoid  arthritis,  though  somewhat  per- 
plexing in  themselves,  tend  strongly,  in  my  opinion,  to  support 
the  view  that  the  disease  is  a  manifestation  of  the  arthritic  dia- 
thesis. Objection  is  made  to  the  inclusion  of  gout  as  a  branch  or 
offshoot  from  the  parent  arthritic  stem,  because  so  many  of  the 
manifestations  of  it  are  non-articular.  I  am  firmly  convinced 
of  this  latter  truth,  but  I  venture  to  think  that  the  arthritic  phe- 
nomena of  gout  are  so  strongly  impressed  on  the  subjects  of  it, 
that  objection  to  the  view  suggested  cannot  fairly  be  raised.  The 
idea  connected  with  an  arthritic  diathesis  implies  tendency  to  dis- 
turbance of  motor  structures  and  the  nervous  centres  regulating 
them,  and  hence  physiologists  conceive  the  possible  existence  of  a 
trophic  nerve-centre,  or  centres,  for  joints.  The  differentiation 
of  Charcot's  joint-disease  has  lent  support  to  this  conception,  and, 
so  far,  there  is  no  evidence  to  disprove  it.      Minute  examinations 

1  Statistics  published  by  the  American  War  Office  in  1875,  under  the  direction  of 
Dr.  Baxter,  and  quoted  by  Mr.  Francis  Galton. 


154      RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 

of  the  spinal  chord  have  yet  to  be  made,  in  order  to  certify  the 
existence  of  any  definitely  associated  lesion  in  rheumatoid  arthritis 
or  other  arthritic  diseases. 

As  a  rule,  I  think  it  may  be  affirmed  that  rheumatoid  arthritis 
is  commonly  seen  unassociated  with  other  diseases.  Dr.  Sutton 
has  called  attention  to  cases  met  with  in  young  persons  where 
this  disorder  seems  to  be  associated  with  phthisis  and  insanity  in 
the  family,  and  believes  that  there  is  some  special  relation  between 
these  conditions.  He  is,  further,  of  opinion  that  there  is  relation, 
not  as  yet  recognized  sufficiently,  between  rheumatoid  arthritis, 
rheumatic  arthritis  with  heart-disease,  also  gouty  arthritis  and 
insanity.  He  thinks  that  these  diseases  have  been  too  much 
regarded  as  definite  entities,  and  that  thus  we  have  been  blinded 
to  their  correspondence. 

Charcot  has  noted  the  not  infrequent  association  with  scrofula 
and  pulmonary  phthisis  in  the  family  and  collateral  relatives  of 
patients,  also  the  frequent  coexistence  of  Heberden's  nodes  with 
mammary  and  uterine  cancer.  In  all  these  coincidences  I  see  no 
more  than  the  Mendings  and  inevitable  coalescences  of  diatheses. 

The  strumous  condition  may  readily  modify  the  arthritic,  and 
the  arthritic  determinations  of  the  former  are  sufficiently  well- 
recognized.  M.  Charcot's  and  Dr.  Sutton's  cases  may  be  explained, 
I  think,  by  the  occasional  coalescence  of  other  taints,  such  as 
struma  or  cancer,  or  of  other  inherited  neuroses  with  the  arthritic 
predisposition. 

The  association  of  diabetes  is  certainly  rare.  Garrod  has 
recorded  one  case,  and  informs  me  that  he  has  seen  others  in  which 
glycosuria  occurred,  and  he  conceives  that  this  may  aid  the  deve- 
lopment of  the  rheumatic  affection.  Dr.  Ord  and  I1  have  recorded 
instances.  Lancereaux  has  observed  the  coincidence  but  rarely. 
Charcot  has  never  met  with  it.  The  association  of  glycosuria  in 
the  gouty  branch  of  the  arthritic  stock  is,  on  the  contrary,  well- 
marked,  and  constitutes  a  determining  symptom. 

I  have  not  observed  a  frequent  occurrence  of  psoriasis  with 
rheumatoid  arthritis,  as  has  been  noted  by  Garrod,  though  the 
skin-disorder  is  certainly  in  itself  a  manifestation  of  arthritic 
disposition. 

The  views  concerning  rheumatoid  arthritis  which  commend 
themselves  to  me  may  be  set  forth  in  the  following  series  of  pro- 
positions : — 

1  See  "Diabetes  in  Relation  to  Arthritism,"  St.  Bartholomew's  Hospital  Reports, 
vol.  xviii.  1882,  p.  371. 


author's  views  on  chronic  rheumatic  arthritis.    155 

That  there  is  a  basic  arthritic  stock,  or  diathesis,  from  which 
arise  as  branches  two  main  classes  of  disorder,  commonly  recog- 
nized as  rheumatism  and  gout. 

That  rheumatoid  arthritis  is  one  of  several  manifestations  of 
this  diathesis,  and  should  be  regarded  as  a  rheumatic  branch  of 
this  stock,  and,  therefore,  a  true  rheumatism. 

That  this  nosological  position  necessarily  entails  indirect  rela- 
tion with  all  forms  of  rheumatism  and  gout. 

That  although  the  disease  has  indirect  relations  with  other 
branches  of  the  arthritic  family,  its  occurrence  is  not  at  any  period 
antagonistic  to  the  onset  of  other  phases  of  rheumatic  and  gouty 
disorder.  Albeit,  the  disease  is  commonly  met  with  in  a  pure 
form,  and  uninfluenced  by  other  arthritic  manifestations. 

That  rheumatoid  arthritis  occurs  specifically  in  more  or  less 
grave  form,  and  may  also  be  developed  symptomatically  by  cer- 
tain special  agencies. 

That  arthritically  disposed  persons  are  peculiarly  vulnerable  and 
sensitive  to  changes  of  temperature,  soil,  and  climate,  and  mani- 
fest this  for  the  most  part  by  certain  trophic  changes  in  the  joints. 

That  gouty  manifestations  may  supervene  independently  in  the 
subjects  of  rheumatoid  arthritis,  or  may  coalesce  with  rheumatic 
conditions  ;  and  that,  in  the  course  of  many  generations,  transi- 
tional modifications  may  occur,  and  give  rise  to  unusual  forms  of 
arthritis  whose  place  is  not  quite  readily  determined. 

That  some  of  these  irregular  forms  may  be  due  to  coalescence 
with  other  inherited  diathetic  states. 

That  accurate  family  and  clinical  histories  are  essential  for 
accurate  diagnosis  in  any  case. 

That  arthritic  persons  are  more  than  others  sensitive  to  ure- 
thral irritation,  gonorrhoea!,  and,  perhaps,  some  other  specific 
poisons,  and  also  liable  to  certain  forms  of  inflammation  of  the 
eye ;  but  that  these  troubles  are  distinctly  more  common  in  the 
gouty  than  in  the  rheumatic  branch. 

That  heredity  is  a  strongly  marked  feature  of  the  arthritic 
diathesis,  and  that  gouty  or  rheumatic  affections  may  supervene 
in  the  descendants  of  either  rheumatic  or  gouty  persons. 

That  local  forms  of  rheumatic  disease  plainly  indicate  the 
underlying  rheumatic  habit  of  body,  which  may  have  previously 
been  latent. 

That  there  are  probably  allied  forms  of  rheumatism  with 
various  manifestations  ;  for  example,  that  state  expressed  merely 
by  the  occurrence  of  nodules  in  the  skin,  fascias,  periosteum, 
sometimes  with,  and  sometimes  without,  associated  carditis. 


156       RELATION    OF    GOUT    TO    OTHER    MORBID    STATES. 

That  although  there  is  an  indirect  relationship  between  rheu- 
matism and  gout,  the  two  diseases  are  remarkably  distinct  from 
each  other,  as  well  as  from  rheumatoid  arthritis. 

That  the  nervous  system  is  markedly  implicated  in  the 
arthritic  diathesis,  and  that  many  of  the  features  both  of  rheu- 
matic and  gouty  diseases  point  to  the  probability  of  there  being 
a  trophic  centre  for  the  joints  situated  in  the  spinal  chord ;  and 
that  a  morbid  or  unstable  condition  of  this  centre  may  result  in 
a  definite  neurosis,  which  may  be  either  inherited,  acquired,  or 
modified. 

That  it  is  not  necessary  to  conceive  of  the  perverted  chemical 
conditions,  so  far  as  they  are  discoverable,  in  either  rheumatism 
or  gout,  as  other  than  epiphenomenal,  and  constituting  but  a 
part  of  the  dynamic  state  induced  by  these  maladies. 

That  the  term  "  rheumatic  gout "  should  be  expunged  from  our 
nomenclature,  and  "  chronic  rheumatic  arthritis,"  the  term  pro- 
posed by  Robert  Adams,  be  employed  in  its  stead. 

2.— The  Relation  between  Gout  and  Lead-Impregnation 
or  Saturnism. 

The  connection  between  lead-poisoning  and  gout  is  well-esta- 
blished, although  the  nature  of  that  connection  is  still  but 
little  understood.  It  is  not  too  much  to  assert  that  the  facts 
adduced  on  this  subject  by  Sir  Alfred  Grarrod,  first  in  1854,  and 
subsequently  added  to  by  him,  have  been  fully  confirmed  by 
other  observers,  and  the  merit  of  fully  setting  forth  the  con- 
nection between  the  two  disorders  rests  with  him,  although  pre- 
vious indications  of  it  were  made  known  more  than  a  century 
ago.1  Garrod  states  that  "at  least  one  in  four  of  the  gouty  patients 
who  had  come  under  his  care  in  hospital  had  at  some  period  of 
their  lives  been  affected  with  lead,  and  for  the  most  part  fol- 
lowed the  occupation  of  plumbers  or  painters."  2  In  i870,3he 
stated  that    33  per  cent,  of  people  who  suffered  from  gout  had 

1  Dr.  William  Musgrave  is  believed  to  be  the  first  writer  who  directed  attention 
to  arthritis  in  connection  with  colic.  He  did  not,  however,  attribute  the  latter 
to  the  influence  of  lead,  but  thought  that  cider-drinking  induced  it.  A  perusal  of 
his  chapter  De  Arthritide  ex  Colicd  in  his  Dissertatio  de  Arthritide  Symptomatica 
makes  this  clear.  This  was  published  in  Exeter  in  1703.  It  was  left  for  the  acu- 
men of  Sir  George  Baker  to  discover,  sixty-three  years  later,  that  lead-impregnation 
of  cider  was  the  real  cause  of  Devonshire  colic,  a  fact  which  he  disclosed  in  an  essay 
read  in  the  College  of  Physicians  on  June  29,  1767. 

2  Clin.  Lect,  on  Lead-Poisoning,  Lancet,  1870,  vol.  ii.  p.  781,  and  Reynolds'  Syst. 
of  Med.,  vol.  i.  p.  841,  Lancet,  1872,  vol.  i.  p.  1. 

3  Gout  and  Rheumatic  Gout,  31  d  edit.,  p.  237. 


GOUT   AND    LEAD-IMPREGNATION.  I  57 

been  poisoned  with  lead.  These  facts  are  very  remarkable,  and 
are  probably  insufficiently  realized.  Such  an  experience  is  not 
readily  procurable,  and  London  practice  affords  perhaps  the  only 
field  in  which  such  a  study  is  possible  on  a  similar  scale.1 

The  connection  between  lead-influence  and  gout,  whatever  it 
may  be,  is  naturally  to  be  studied  almost  exclusively  amongst  the 
artizan  classes,  and  therefore  in  hospital  practice.  Lead-impreg- 
nation is  now,  happily,  very  rare  amongst  the  upper  classes, 
owing  to  proper  care  in  the  storage  and  supply  of  potable  water. 
Yet  even  here  this  influence  should  never  be  lost  sight  of  in  any 
case.  Amongst  the  artizan  population  of  London  it  is  common 
to  meet  with  cases  of  lead-poisoning,  but  the  worst  cases  are 
seen  in  the  workers  in  lead-mills.  These  persons  are  generally 
very  poor,  and  only  resort  to  this  occupation  when  other  means 
fail  them.  I  find  that  they  are  often  Irish,  and  that  many 
women  are  amongst  them,  and  it  is  not  without  importance  to 
note  these  facts. 

My  own  experience  is  taken  from  a  series  of  136  cases  of 
unequivocal  gout  in  both  sexes,  which  came  under  my  care  some 
years  ago  amongst  the  out-patients  at  the  Hospital.  Twenty- 
five  of  these  patients,  or  1  8  per  cent.,  presented  signs  of  lead- 
impregnation,  and  followed  the  occupation  of  painters,  plumbers, 
compositors,  or  workers  in  lead-mills.  They  were  all  males. 
The  age  of  the  youngest  was  twenty-five,  of  the  oldest  sixty-two, 
the  mean  being  about  forty-three  years.  In  seventeen  of  the 
cases  there  were  either  present,  or  there  were  histories  of,  blue 
line  on  the  gums,  colic,  and  wrist-drop.  In  at  least  one-half  of 
these  patients,  there  was  history  of  intemperance,  commonly  in 
both  malt  liquors  and  spirits.  In  at  least  one-half,  the  urine  was 
slightly  albuminous,  of  low  specific  gravity,  and  there  were 
histories  of  cramps  in  the  legs  and  of  nocturnal  micturitions — 
all  symptoms  of  chronic  interstitial  nephritis. 

These  cases  are  taken  from  my  note-books,  and  under  the 
pressure  of  hospital  work  facts  of  lesser  importance  have  been 
sometimes  omitted.  They  were  recorded  for  no  special  object, 
and  simply  to  illustrate  the  varied  phenomena  of  gouty  disease. 
The  percentage  of  saturnine  gout  is  large  and  remarkable,  but 
it  is  considerably  under  that  recorded  by  Garrod,  viz.,  18  against 
3  3  per  cent,  of  all  cases  of  true  gout. 

1  Vide  Cases  in  the  Acute  Rheumatism  and  the  Gout,  by  Thos.  Dawson,  M.D., 
late  Physician  to  the  Middlesex  and  the  London  Hospitals,  Lond.  1774,  p.  83.  Case 
of  a  glazier  and  painter,  gouty  from  nine  years  of  age.  Dropsy  and  asthma  followed. 
Dr.  Dawson  suspected  the  deleterious  quality  of  the  lead  as  laying  the  foundation  of, 
or  at  least  aggravating,  the  complaints. 


I58       RELATION    OF    GOUT    TO    OTHER    MORBID    STATES. 

Garrod  sought  to  ascertain  how  far  his  views  were  borne  out 
by  experience  obtained  in  other  places,  and  he  quotes  the  evi- 
dence of  Sir  Robert  Christison,  which  showed  that  both  lead- 
poisoning  and  gout  were  practically  unknown  in  the  Edinburgh 
Infirmary. 

I  have  endeavoured  to  gather  some  new  facts  in  reference  to 
this  matter,  and  now  communicate  the  experiences  of  several 
eminently  competent  observers  in  various  cities  and  manufactur- 
ing centres. 

In  Edinburgh,  Professor  Grainger  Stewart  finds  that  the  same 
immunity  both  from  lead-poisoning  and  from  gout  still  prevails, 
and  he  thus  confirms  Sir  Robert  Christison's  evidence  in  reply  to 
Garrod's  inquiries  in  1859. 

He  remarks,  "  Although  I  see  a  great  deal  of  gout  in  my  con- 
sulting-room here,  I  do  not  find  it  increasing  among  the  Infirmary 
patients — indeed,  I  scarcely  ever  get  a  case.  I  may,  however, 
say  that  during  the  years  I  have  been  in  practice,  I  have  gradually 
gleaned  evidence  enough  to  satisfy  me  of  the  correctness  of  the 
view  which  was  believed  in  by  Warburton  Begbie  and  others 
here." 

It  is  interesting  to  point  out  that  the  views  of  Sir  Robert  Chris- 
tison, as  expressed  to  Garrod  in  1859,  did  not  meet  the  approval 
of  the  late  Dr.  Warburton  Begbie,  for,  three  years  subsequently, 
he  denied  the  great  infrequency  both  of  lead-poisoning  and  of 
gout  in  the  same  sphere  of  observation — to  wit,  the  Edinburgh 
Royal  Infirmary.  He  published  the  particulars  of  two  cases  fully 
illustrating  the  connection,  and  declared  that  he  had  met  with 
about  twelve  of  the  kind  in  the  course  of  seven  years.  In  both 
of  his  published  cases  there  was  history  of  intemperance  in  spirits 
as  well  as  in  malt  liquors.1  He  believed  that  lead-impregnation, 
together  with  the  employment  of  fermented  liquors,  gave  strong 
predisposition  to  gout. 

Professor  Gairdner,  of  Glasgow,  writes  that  his  experience  is 
entirely  negative.  He  says,  "  I  never  saw  a  case  of  lead-poison- 
ing in  association  with  gout  having  its  genesis  in  Scotland.  I  will 
not  say  that  my  experience  in  this  matter  is  to  be  taken  as 
absolute  ;  only,  as  lead-poisoning  and  gout  are  each  rather  rare  in 
the  working-classes  here,  the  combination  is,  of  course,  still  more 
uncommon.  I  have  no  doubt  of  the  London  facts,  also  little 
doubt  that  beer  is  a  large  factor." 

Supposing  that  lead-impregnation  must  be  common  at  New- 
castle-on-Tyne,   I  addressed  my  friend  Dr.  Drummond,   who  is 
1  Edin.  Med.  Jour.,  August  1862,  p.  125. 


GOUT    AND    LEAD-IMPREGNATION.  1 59 

physician  and  pathologist  to  the  Infirmary  there,  with  reference 
to  any  gouty  prevalence.  He  replied  as  follows: — "I  think  I 
may  state  very  positively  that  in  Newcastle  and  district,  where 
we  meet  with  a  very  large  number  of  cases  of  lead-impregnation, 
we  never  see  gout  associated  with  that  condition.  Such  is  my 
own  experience,  and  I  have  given  a  great  deal  of  attention  to 
lead-poisoning,  having  ample  material  in  the  Infirmary  to  draw 
from.  It  is  also  the  experience  of  Dr.  Embleton,  our  consulting 
physician,  and  for  a  long  time  medical  officer  in  charge  of  nearly 
all  the  lead-factories  in  the  neighbourhood.  We  see  lead-kidney 
(granular),  lead-encephalopathy,  fits,  optic  neuritis,  optic  atrophy, 
lead-palsies  of  upper  and  lower  extremities,  lead-colic,  and  lastly, 
lead-arthralgia ;  but  I  have  never  seen  anything  like  gout  in  a 
lead  case.  The  arthralgia  has  always  appeared  to  me  to  be  more 
of  a  myalgia  than  a  joint-affection  proper.  Some  of  the  cases  are 
allied  to  subacute  rheumatism  without  effusion  into  the  joints,  but 
unlike  gout.  We  do  not  often  meet  with  gout  in  Newcastle,  and 
it  is  very  rare  amongst  the  lower  orders."  As  to  the  liquors  con- 
sumed by  the  labouring  classes,  Dr.  Drummond  states  that  a 
great  deal  of  whisky  is  drunk  as  well  as  beer.  "  The  chemical 
labourers  drink  whisky  to  '  kill  the  gases,'  as  they  say,  but  the 
pitmen  drink  both  ale  and  whisky.  On  the  whole,  I  may  say 
that  '  halves  of  whisky '  is  the  favourite  drink." 

Sir  Walter  Foster  informs  me  that  lead-poisoning  is  not  com- 
mon in  Birmingham,  and  that  very  little  gout  is  seen  amongst 
the  lower  orders. 

Dr.  Wynne  Foot,  senior  physician  to  the  Meath  Hospital  in 
Dublin,  states  that  he  is  "  quite  familiar  with  articular  symptoms 
in  painters,  plumbers,  and  others  exposed  to  lead-intoxication." 
He  terms  the  affection  plumbic  arthritis,  and  has  come  to  regard 
it  as  a  form  of  spinal  arthropathy  due  to  poisoning  of  the 
nerve-centres.  He  has  not  had  any  -post-mortem  examination  of 
these  cases. 

Professor  Cuming,  of  Belfast,  reports  that  his  experience  is 
decidedly  against  the  connection,  for  which  he  has  often  looked, 
and  always  in  vain. 

The  evidence  here  amounts  to  this,  that  lead  is  a  factor  in  the 
production  of  arthritis,  the  nature  of  which  is  not  exactly  known. 
It  may  be  presumed  that  no  manifest  gouty  characters  prevailed, 
or  they  would  certainly  have  been  noted.  Gout  is  rare  in 
Dublin,  although  it  has  been  stated  to  have  become  more  frequent 
since  the  lower  orders  have  taken  to  drinking  porter  instead  of 


l6o      RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 

In  Liverpool,  both  gout  and  lead-poisoning  appear  to  be  very 
rarely  met  with.  I  have  before  me  the  experience  of  three  of 
the  physicians  to  the  largest  hospitals  in  the  city,  Dr.  Cameron, 
Dr.  Waters,  and  Dr.  Davidson,  and  it  furnishes  no  facts  in  sup- 
port of  the  relationship. 

With  respect  to  Paris,  we  find  the  evidence  of  Charcot  in 
1868  to  the  effect  that  "II  existe  parmi  les  satumins  quelques 
goutteux,  chez  qui  l'empoisonnement  par  le  plomb  est  la  seule 
cause  qu'on  puisse  invoquer."  He  believes  that  gout  may  be 
developed  under  this  influence  alone,  but  that  such  cases  are 
rare.  He  has  published  one  example  illustrating  this.  Lan- 
cereaux has  contributed  some  important  facts  from  his  experience 
at  La  Pitie.  He  communicated  to  the  International  Medical 
Congress  a  series  of  twenty-four  cases  of  saturnine  nephritis,  and 
from  this  list  I  find  that  in  over  one-third  of  the  cases  there  was 
distinct  history  of  gout,  or  of  uratic  infiltration  of  joints.  I  think, 
too,  that  had  the  joints  been  examined  in  all  his  cases,  a  still 
larger  proportion  of  gouty  evidence  would  have  been  forthcoming. 
In  respect  of  the  dietetic  habits  of  these  patients,  Lancereaux 
informs  me  that  many  of  them  had  drunk  brandy  and  absinthe 
to  excess,  and  were  also  wine-drinkers.  In  no  case  was  there 
history  of  excessive  beer-drinking.  These  cases  plainly  illustrate 
the  combination  of  lead-impregnation  and  alcoholic  excess  as 
factors  in  the  production  of  gout  in  a  community  and  country 
where  that  malady  but  seldom  occurs.  Lancereaux  agrees  with 
those  observers  who  believe  that  the  lesions  of  gout  and,  so-called, 
saturnine  gout  are  identical  in  all  the  organs  of  the  body,  save 
that  in  pure  gout  there  may  perhaps  be  present  more  uratic 
deposit ;  but  he  does  not  believe  that  intemperate  habits  count 
for  much  in  the  production  of  urate  of  soda  and  of  gout,  for  the 
reason  that  his  hospital  practice  yearly  furnishes  him  with  hun- 
dreds of  cases  of  alcoholic  excess  amongst  which  gout  is  most  rarely 
seen,  and  when  met  with,  is  regarded  merely  as  a  coincidence. 

It  is  to  be  noted  that  the  kidneys  were  severely  implicated  in 
the  majority  of  Lancereaux's  cases. 

Dr.  Pye-Smith,  in  a  series  of  sixty-one  cases  of  gout  at  Guy's 
Hospital,  met  with  evidence  of  plumbism  in  only  two  instances. 
He  does  not  find  that  plumbers  and  painters  admit  the  common 
opinion  that  men  in  these  trades  drink  more  freely  than  others.1 
(My  own  observation  in  London  would  not  permit  me  to  grant 
this  admission.)  In  these  cases  there  was  history  of  inherited 
gout  or  of  intemperance. 

1  Analysis  of  Cases  of  Rheumatism  and  Gout,  Guy's  Hospital  Reports,  1873. 


GOUT   AND   LEAD-IMPREGNATION.  l6l 

It  is  important  to  note  the  influences  of  lead  in  cases  of  gout 
where  no  inherited  taint  is  discoverable,  and  also  where  no  intem- 
perance in  strong  drinks  has  prevailed  to  determine  gout.  Char- 
cot x  reports  one  such  case — Todd's 2  was  probably  of  this  nature 
— and  Dr.  Wilks3  has  recorded  three  instances.  In  the  great 
majority  of  cases  there  is  found  history  either  of  predisposition  to 
gout,  or  of  distinct  intemperance  in  malt  liquors,  or,  indeed,  of 
both  causes ;  but  none  the  less  is  the  influence  of  saturnism  very 
decided  and  noteworthy. 

Dr.  Begbie's4  cases  occurred  in  intemperate  men,  and  the  late 
Dr.  Falconer5  reported  another.  Dr.  Fagge6  also  recorded  one. 
M.  Bricheteau 7  recorded  a  case  in  a  painter  whose  father  had 
followed  the  same  occupation ;  and  amongst  my  own  cases  are 
three  where  the  fathers  were  either  painters  or  compositors.  In 
these  instances  we  must  regard  it  as  almost  certain  that  predis- 
position to  arthritism  existed,  or  was  directly  inherited.  Great 
difficulty  must  always  be  met  with  in  eliciting  ancestral  history 
of  gout,  especially  in  the  cases  of  hospital  patients ;  and  another 
difficulty  arises  from  the  impossibility  of  finding  certain  evidence 
of  lead-taint  in  some  instances,  since  such  may  really  be  present 
without  the  manifestations  of  colic,  wrist-drop,  or  even  of  the 
Burtonian  blue  line.8  Lancereaux's  cases  all  occurred  in  intem- 
perate men. 

London  experience  certainly  confirms  Garrod's  opinion  that 
persons  exposed  to  lead -influence  are  prone  to  develop  gout,  and 
that  persons  of  gouty  predisposition  are  specially  liable  to  suffer 
quickly  and  severely  from  plumbism.  It  is  remarkable  that  this 
experience  should  not  be  universal  even  in  England.  It  is, 
however,  noteworthy  that  in  many  cases  where  true  gout  is  not 
developed  in  connection  with  lead-impregnation,  rheumatoid  pains 
and  arthritis  are  apt  to  supervene,  and  this  fact  appears  to  me 

i  Gazette  Hebdom.,  1863,  No.  xxvii.  p.  433. 

2  On  Gout  and  Rheumatism,  1843,  p.  44. 

3  Guy's  Hosp.  Reports,  1870,  p.  40. 

4  Loc.  cit. 

5  Brit.  Med.  Journal,  186 1,  p.  464. 

6  Med.  Chir.  Trans.,  vol.  Ixiv.  p.  221. 

7  Gazette  des  Hopitaux,  1870,  No.  xxvi. 

8  My  observations  entirely  confirm  Dr.  Hilton  Fagge's  respecting  the  blue  (more 
correctly  black)  line.  Vide  Med.  Chir.  Trans.,  vol.  lix.  p.  327.  Garrod  has  claimed 
the  credit  of  its  discovery  for  Tanquerel  des  Planches,  who  published  his  famous 
TraiU  des  Maladies  de  Plomb  ou  Saturnines  in  1839.  Dr.  Burton's  communica- 
tion was  read  to  the  Royal  Medical  and  Chirurgical  Society  in  January  1840,  but 
he  stated  that  he  first  discovered  the  blue  line  in  1834,  and  waited  to  confirm  his 
observations.  He  also  described  articular  pains  "resembling  rheumatism"  in  lead- 
impregnation.     (Dr.  Burton  was  physician  to  St.  Thomas's  Hospital.) 

L 


1 62       RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

to  justify  the  view  held  by  Dr.  Wynne  Foot,  Lancereaux,  and 
perhaps  others,  that  the  arthritis  owns  a  neurotic  origin.  And  this 
theory  is  specially  acceptable  to  me,  inasmuch  as  I  am  strongly 
convinced  of  the  neurotic  element  in  gouty  disease  in  general. 
Lancereaux  believes  the  pathogeny  of  ordinary  and  of  saturnine 
gout  to  be  alike,  and  holds  that  they  have  their  common  origin 
in  "  a  primordial  trouble  of  nutritive  innervation."  He  remarks, 
"  Gout  is  certainly  the  result  of  such  a  disorder,  and  no  one  can 
doubt  the  obvious  action  of  lead  upon  the  nervous  system." 

In  connection  with  arthritic  changes  induced  by  lead,  attention 
may  be  directed  to  a  series  of  cases  which  were  very  carefully 
described  in  Paris  in  1868  by  M.  Gubler,1  M.  Nicaise,2  and  M. 
Bouchard.3  A  series  of  fourteen  cases  illustrated  certain  swellings 
which  appeared  in  the  extensor  tendons  and  their  sheaths  in  con- 
nection with  muscular  atrophy  and  wrist-drop.  Sometimes  the 
carpal  and  metacarpal  bones  were  affected  by  bony  outgrowths, 
and  in  several  instances  arthritis  occurred  in  the  metacarpo- 
phalangeal and  phalangeal  joints.  Gout  and  uratic  deposits  appear 
to  have  been  carefully  excluded,  save  perhaps  in  one  case.  The 
extensor  tendons  and  tarsal  bones  were  also  affected  in  some  cases. 
These  swellings,  to  which  M.  Gubler  gave  the  name  of  "  dorsal 
tumour  of  the  hands,"  were  found  to  occur  commonly  within  two 
months  of  the  onset  of  the  paralysis.  Sometimes  they  were  formed 
within  a  few  days,  and  in  others  not  till  six  months  had  elapsed. 
After  death,  the  tendons  and  their  sheaths  were  found  to  be  nodu- 
lar and  the  synovia  opaque,  and  bony  outgrowths  had  occurred, 
but  no  uratic  incrustation.  These  tumours  entirely  subsided  in 
several  of  the  cases,  but  a  good  deal  of  inflammatory  disturbance 
and  pain  were  met  with  at  first.  M.  Nicaise  in  his  papers  showed 
that  similar  cases  had  been  noted  nearly  three  centuries  ago  by 
Plater,  and  by  De  Haen  in  1745,  also  by  Pariset  in  18  13,  and 
by  Tanquerel  des  Planches  in  1839.  M.  Gubler  recognized  the 
same  affection  in  one  case  of  hemiplegia  due  to  cerebral  hsemor- 
rhage ;  and  in  1869  M.  Tournie4  contributed  three  cases,  the 
tumours  always  occurring  in  the  hand  of  the  paralyzed  side. 

M.  Gubler  regarded  these  changes  as  due  to  enfeeblement  of 
vaso-motor  nerves,  and  such  cases  must  be  considered  together 
with  those  which  are  distinctly  gouty  in  their  nature,  all  of  them 
plainly  illustrating  neuro-trophic  derangements.  Erb 5  declares 
his  belief  that  in  lead-poisoning  there  is  a  primary  lesion  of  the 

1  L'Union  Mid.,  1868.  2  Gazette  Mid.,  1868. 

•  s  Gaz.  Hebdom.,  1868.  4  L' Union  Med.,  1869. 

5  Disease  of  Peripheral  Cerebro- Spinal  Nerves,  Ziemssen's  Cyclop.,  vol.  xi.  p.  548. 


GOUT    AND    LEAD-IMPREGNATION.  163 

nervous  system,  mainly  spinal,  leading  to  motor-trophic  disturb- 
ances, and  lie  quotes  observations  by  Remak  showing  that  cir- 
cumscribed alterations  are  met  with  in  the  anterior  cornua  of  the 
chord.1 

The  effect  of  plumbism  in  inducing  arthritis  other  than  gouty, 
and  articular  pains,  as  well  as  the  peculiar  swellings  in  the  tendons 
of  the  extremities  and  their  sheaths,  must  be  considered  in  relation 
to  the  production  of  true  gout  in  many  cases.  These  may  be  held 
to  be  of  neuropathic  nature,  and  akin  to  other  forms  of,  so-called, 
spinal  arthropathy. 

Lead-taint  superadded  to  already  existing  arthritic  diathesis, 
or  coalescing  with  ordinary  excitants  of  gout,  appears  to  promote 
and  intensify  the  evolution  of  gout. 

It  has  been  stated  in  objection  to  the  theory  of  any  connection 
between  plumbism  and  gout,  that  the  cases  should  be  more  com- 
mon than  they  are,  and  that  women  should  present  examples  of  it. 
But  the  cases  illustrating  the  connection  in  males  form  a  very 
remarkable  percentage  of  all  cases  of  true  gout ;  and  the  fact  that 
women  are  apparently  exempt  may  admit  of  the  explanation  that 
they  are  seldom  persistently  exposed,  as  are  men,  to  lead-impreg- 
nation. Women  who  suffer  are  commonly  employed  for  short 
periods  in  lead-mills.  They  mostly  take  up  the  work  in  default 
of  other  and  more  wholesome  employment,  and  leave  it  as  soon  as 
they  can.  Women,  too,  are  less  subject  to  gout  during  the  period 
of  generative  activity  than  men,  and  they  are  certainly  more 
temperate  in  liquors.  Amongst  my  cases,  most  of  the  women 
affected  by  lead  were  Irish,  and  very  destitute.  Now,  it  may 
be  affirmed  that  in  such  instances  there  is  absence,  for  the  most 
part,  of  both  the  factors  of  hereditary  tendency  to  gout,  and  of 
intemperate  habits.  I  see  many  cases  of  gout  in  Irishmen  who 
have  lived  long  in  London,  and  who  have  almost  certainly  acquired 
the  malady  as  the  result  of  adoption  of  London  habits  of  beer- 
drinking.  Such  men  would  probably  never  have  become  gouty 
in  Ireland. 

Women  who  acquire  lead-cachexia  manifest  all  the  lesions  pro- 
ducible by  the  metal,  save  unequivocal  gout.  They  suffer  the 
cardio-vascular  and  the  renal  changes  very  markedly,  but  the 
special  uric  acid  perturbations  are  not  found. 

The  facts  relating  to  lead-impregnation  and  chronic  interstitial 
nephritis  admit  of  no  question  in  either  sex.  LanceVeaux  draws 
a  distinction  between  the  kidneys  of  plumbism  and  those  result- 
ing  from    arterio-capillary   fibrosis    unconnected   with    saturnine 

1  Vol.  xiii.  p.  715. 


164      RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

influence.  In  the  latter,  he  finds  the  granulations  coarser  and 
more  irregular,  the  arterioles  more  thickened,  and  the  changes 
unequal  in  the  two  organs.  Together  with  the  granular  kidneys 
associated  with  purely  vascular  change,  he  has  observed,  in  a  pro- 
portion of  his  cases,  certain  forms  of  arthritis  quite  distinct  from 
gout,  and  more  allied  to  osteo  or  rheumatoid  arthritis,  no  uratic 
deposit  being  present.1  The  joints  chiefly  affected  are  the  meta- 
carpophalangeal of  the  thumb  and  the  knees.  Such  cases  have 
not,  I  believe,  been  hitherto  differentiated  in  this  country.  Where 
the  characters  of  saturnine  nephritis  prevail,  Lancereaux  has,  with 
one  exception,  found,  when  he  has  looked  for  it,  the  arthritic 
changes  characteristic  of  gout,  viz.,  uratic  deposits  in  the  struc- 
tures of  the  joints. 

In  the  large  number  of  cases  of  lead-poisoning  carefully  re- 
corded by  Tanquerel  des  Planches,  it  is  remarkable  that  there 
is  no  mention  of  gout.2  The  characters  of  lead-arthralgia  are 
minutely  described,  and  in  frequency  it  is  accorded  the  second 
place  as  a  symptom,  colic  being  nearly  twice  as  often  met  with. 
Arthralgia  was  found  to  be  most  frequent  during  the  summer 
season,  and  to  occur  more  commonly  in  the  fourth  decade.  The 
joints  of  the  lower  limbs  suffered  chiefly,  while  the  upper  extre- 
mities were  affected  by  paralysis.  It  is  specially  mentioned  that 
there  were  never  observed  heat,  redness,  or  swelling,  and  that 
pressure  relieved  the  pain. 

The  special  susceptibility  of  the  gouty  to  be  affected  by  lead, 
as  asserted  by  Garrod,  appears  to  be  unquestionable.  In  some 
cases,  lead  has  induced  the  first  obvious  symptoms  of  gout, 
having,  as  it  were,  precipitated  the  specific  morbid  processes  of 
gouty  inflammation,  and  forming  a  sort  of  touch-stone  for  this 
taint.3 

A  consideration  of  the  physiological  action  of  lead  upon  the 
body  shows  that  both  the  nervous  and  circulatory  systems  are 
profoundly  affected.  Lead  has  been  found  in  most  of  the  tissues 
after   death,    especially    in    the    brain 4  and   in   the   intestines.5 

1  Communication,  with  specimens  of  affected  bones,  to  the  Section  of  Medicine, 
International  Medical  Congress,  London,  August  1881. 

2  Intemperance  has,  however,  increased  greatly  amongst  the  lower  orders  in  Paris 
and  the  large  French  towns  during  the  last  forty  years. 

3  My  colleague,  Dr.  Lauder  Brunton,  kindly  permits  me  to  report  the  following 
case,  which  he  observed  a  few  years  ago  amongst  the  casualty  patients  : — A  man, 
aged  twenty-five  to  thirty,  came  under  his  care  for  chronic  diarrhoea.  He  was  treated 
with  pil.  plumbi  c.  opio.  In  less  than  ten  days  he  returned  with  gout  in  one  of 
his  joints.     He  had  never  had  a  previous  attack  of  gout. 

4  Troisier  and  Lagrange,  Gaz.  Med.,  1S74,  62. 

5  Fagge  and  Stevenson,  loc.  cit.,  1S80. 


GOUT  AND    LEAD-IMPREGNATION.  1 65 

Gaffky x  believes  that  some  change  occurs  in  the  vaso-motor 
nerves  of  the  abdomen,  especially  in  the  sympathetic  fibres  of 
the  splanchnic,  by  reason  of  which  the  renal  mischief  is  iuduced. 
Kussmaul  and  Maier 2  record  a  careful  post-mortem  examination 
of  a  case  of  chronic  lead-poisoning,  in  which,  amongst  many 
other  changes,  they  found  proliferation  and  sclerosis  of  the  con- 
nective-tissue septa  of  the  small  ganglia  of  the  sympathetic, 
especially  the  cceliac  and  cervical.  These  ganglia  were  hard,  and 
the  nerve-cells  diminished.  The  smaller  arteries  were  narrowed, 
and  periarterial  thickening  was  widely  spread.  It  is  not  easy 
to  follow  the  exact  sequence  or  relation  of  these  changes,  but 
it  is  known  that  under  the  influence  of  lead  the  action  of  the 
heart  becomes  slow,  and  that  the  arterial  tension  is  raised.3  It 
is  also  now  well  ascertained  that  a  persistent  condition  of  high 
arterial  pressure  is  in  itself  a  certain  source  of  cardiac  hyper- 
trophy and  arterial  thickening,4  and  it  may  well  be  that  much 
of  the  mischief  wrought  by  lead-impregnation  is  set  up  in  this 
fashion,  the  particular  form  of  kidney- affection  met  with  in  this 
cachexia  being  associated  with  it.  The  presence  of  retained 
matters,  such  as  uric  acid,  in  the  blood  is  certainly  often  associated 
with  a  condition  of  arterio-capillary  fibrosis,  and  this  impure 
blood  has  been  supposed  to  meet  with  resistance  in  the  smaller 
vessels,  and  to  provoke  higher  arterial  tension  in  consequence. 
It  is,  however,  conceivable  that  this  chain  of  events  may  result 
from  injury  primarily  inflicted  upon  the  sympathetic  system  of 
nerves  by  the  contaminated  blood. 

Garrod  has  demonstrated  that  lead  distinctly  diminishes  the 
secreting  powers  of  the  kidneys  for  uric  acid,5  and  Charcot 6 
likens  this  inhibitory  action  of  the  metal  to  paralysis  of  the 
kidney.  The  uric  acid  is  consequently  retained  in  the  body.' 
Due  regard  being  had  to  these  facts,  it  becomes  easy  to  see  a 

1  Ueber  den  ursacldiclien  Znsammenhang  zwischen  chronischer  Blei- intoxication  und 
Nierenaffectioiien,  Berlin,  1873. 

2  Deutsch.  Arcluv,  ix.  p.  233. 

3  The  best  and  most  recent  research  on  lead-poisoning  is  that  of  Erich  Harnack, 
published  in  the  Archiv  filr  experimentelle  Pathologie  und  Pharmahologie,  IXter 
Band,  Leipzig,  1878,  p.  152.  His  experiments  go  to  support  the  view  that  the  joint- 
affections,  and  the  nervous  symptoms  generally,  are  due  to  irritation  of  different 
centres,  those  in  the  medulla  oblongata  and  the  brain  usually  supervening  latest. 

Naturally,  we  cannot  look  for  much  evidence  as  to  the  relation  of  lead-impregna- 
tion to  gout  from  any  experiments  made  in  the  physiological  laboratory ;  such  proof 
is  only  to  be  obtained  from  clinical  studies. 

4  As  demonstrated  by  Dr.  Mahomed  and  other  observers. 

5  On  Gout,  p.  240. 

f'  Lecons  sur  les  Maladies  des  Vieillards,  &c,  1868,  p.  124. 
7  Dr.  Haig  has  recently  confirmed  this  fact. 


1 66   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

very  close  relation  between  lead-impregnation  and  the  frequent 
occurrence  of  gouty  manifestations.  But  it  is  not  at  once 
obvious  why  gout  should  not  be  more  frequent  in  lead-cachexia 
than  it  really  is.  One  or  more  factors  in  the  causation  are  want- 
ing. Dr.  Pye-Smith 1  has  never  met  with  gout  from  plumbism 
without  hereditary  predisposition  or  intemperance,  and  enough 
has  been  already  shown  to  justify  this  assertion.  We  may 
explain  the  fact  that  gout  is  not  found  to  be  associated  with 
lead-impregnation  to  any  noteworthy  extent  in  the  North  of 
England,  in  Ireland,  and  in  Scotland,  by  a  consideration  of  the 
conditions  of  heredity  and  of  the  drinking  habits  of  the  people 
in  these  various  countries.  There  is,  and  there  has  been  for 
centuries,  more  gout  in  the  English  metropolis,  and  amongst 
the  beer-drinking  inhabitants  of  the  southern  counties  of  Eng- 
land, than  there  is  or  has  been  amongst  the  populations 
in  the  North,  in  Ireland,  and  in  Scotland,  where  spirits  are 
consumed ;  and,  therefore,  it  is  only  to  be  expected  that  the 
Southerners  should  yield  the  largest  return  of  saturnine  gout. 
On  the  other  hand,  beer-drinking  is  not  alone  in  inducing  gouty 
disease,  for  this  will  occur  in  persons  who  have  been  habitual 
spirit-drinkers  only,  and  also  in  those  who,  as  in  the  case  of 
Parisian  artizans,  drink, — immoderately,  it  is  true, — both  brandy 
and  inferior  qualities  of  French  wine.  Hence  we  may  believe  that 
the  two  main  exciting  factors,  inherited  taint  and  intemperance, 
act  often  together,  and  sometimes  singly,  in  producing  saturnine 
gout.  In  these  cases  there  are  certainly  present  two  of  the 
essential  factors  of  gout,  (a)  altered  innervation,  and  (&)  retention 
of  uric  acid  in  the  system. 

The  effect  of  lead  in  inducing  gout  may  probably  be  attri- 
buted to  the  specific  action  of  the  poison  upon  the  nerve-centres, 
this  malign  influence  evoking  such  trophical  changes  in  the 
entire  vascular  system,  and  in  the  kidneys,  as  are  prone  to  be 
produced  by  the  morbid  condition  which  we  recognize  as  gout  in  its 
most  comprehensive  aspect.  The  lines  of  degeneration  in  the  two 
affections,  saturnism  and  gout,  run,  as  it  were,  parallel,  and  seem 
only  to  be  modified  by  individual  habit  and  diathetic  tendency.2 

Dr.  Saundby,  of  Birmingham,3  after  a  careful  review  of  thir- 

1  Op.  cit. 

2  According  to  Pouey,  the  liver  is  mainly  at  fault,  being  disturbed  by  the  action 
of  lead,  with  interruption  to  its  due  metabolic  functions. 

3  Medical  Times  and  Gazette,  September  1881,  pp.  385,  412.  Dr.  Saundby  records 
one  case  in  his  practice  of  a  male,  aged  thirty-nine,  a  file-cutter,  with  no  hereditary 
gouty  taint,  who  had  had  gout  three  years  previously,  with  colic,  and  blue  line  on 
gums.  He  had  been  intemperate  in  beer-drinking.  He  presented  all  the  signs  of 
granular  kidneys  and  cardio-vascular  degeneration. 


FRERICHS    ON   LEAD-IMPREGNATION.  1 67 

teen  cases,  most  of  which  have  just  been  considered,  arrives  at 
the  conclusion  that  the  "  doctrine  of  saturnine  gout  rests  rather 
on  authority  than  on  observation."  A  larger  review  of  all  the 
facts  must,  I  conceive,  lead  to  the  belief  that  the  connection 
between  lead-impregnation  and  gout  is  both  definite  and  unques- 
tionable. The  "authority"  on  which  this  doctrine  rests  is  at 
least  worthy  of  the  highest  respect,  including  as  it  does  a  large 
number  of  physicians  who  have  been,  and  are,  the  keenest 
observers  in  the  widest  and  best  fields  of  study. 

The  late  Professor  Frerichs,  of  Berlin,  was  so  good  as  to  make 
for  me  the  subjoined  analysis  of  163  cases  of  lead-poisoning. 
These  cases  were  all  observed  in  his  clinic,  and  they  have  been 
examined  with  a  view  to  discover  whether  any  gouty  association 
was  noted  in  any  of  them. 

It  will  be  seen  that  the  Berlin  experience  furnishes  evidence 
of  a  negative  character  in  relation  to  this  matter,  and  goes,  so 
far,  to  confirm  the  opinion  expressed  that  the  association  of  gout 
with  lead-impregnation  is  most  distinctly  manifested  where  gout 
commonly  prevails  amongst  the  population. 

Professor  Frerich's  Clinic. 

' '  Service  of  Dr.  Dhrlicli. — An  analysis  of  1 2  2  cases  of  chronic 
lead-poisoning,  of  which  only  four  occurred  in  women,  and  of 
which  only  two  died  (one  patient  having  jumped  from  a  window), 
resulted  in  the  following  : — 

I.  By  lead-colic  were  attacked  ninety-five  men,  three  women. 
Of  these,  one  had  pulmonary  phthisis,  one  croupous  pneumonia, 
and  one  aortic  insufficiency. 

II.  Lead-palsy  attacked  almost  without  exception  the  distribu- 
tion of  the  radial  nerve.  It  was  noted  in  fourteen  men  and  one 
woman. 

a.  The  affection  was  bilateral  in  twelve  cases,  and  was  here 
complicated  six  times  with  lead-colic  and  once  with 
typhus. 

/3.  The  affection  was  unilateral  three  times,  and  always  limited 
to  the  right  arm.      One  of  these  patients  had  colic. 

III.  Lead  arthralgia.      Six  cases,  three  accompanied  by  colic. 

IV.  Affections  of  the  centres. 
a.   Cephalalgia  saturnina. 

/3.  Encephalopathia  saturnina  colica. 
y.   Epilepsia  saturnina  colica. 


1 68      RELATION   OF    GOUT    TO    OTHER   MORBID    STATES. 

S.   Epilepsia  saturnina  8  alucinationibus. 

e.   Epilepsia  saturnina,  amaurosis  fugax,  colica. 

£.   Paralysis  saturnina,  c  poliomyeliti  anteriore  chronica. 

V.    Varia. 

a.  Two  cases  of  circular  gastric  ulcer,  of  which  one  suffered 

perforation  and  proved  fatal. 
/3.   One  case  of  lead-asthma  (phthisis). 

Palpable  changes  in  the  joints  were  not  noted  in  any  of  these 
cases,  nor  were  any  cases  of  nephritis  vera  met  with,  although 
somewhat  frequently,  during  the  existence  of  the  colic,  albumen 
appeared  temporarily  in  the  urine. 

Service  of  Br.  Lit  ten. — In  forty-one  cases  of  lead-poisoning 
(colic,  lead-palsy)  were  six  in  which  joint-affection  was  present, 
generally  appearing  in  a  slight  degree,  and  but  temporarily. 
Only  in  two  cases  was  much  swelling  of  the  joints  of  the  feet. 

However,  in  no  instances  were  symptoms  of  true  gout  present. 

Albumen  was  only  found  four  times  in  these  forty-one  cases, 
and  soon  passed  away. 

Amongst  these  163  cases  of  lead- poisoning,  sometimes  slight 
and  sometimes  severe,  there  was  not  one  single  case  of  true  gout. 
Also  in  no  case  was  nephritis  chronica  present. 

Besides  these,  I  have  about  200  other  cases  which  I  have  not 
been  able  to  analyze  on  account  of  illness,  but  I  am  confident 
that  in  not  one  case  amongst  them  was  true  gout  present. 

My  experience  does  not  agree  with  that  of  Lance'reaux  respect- 
ing nephritis  and  saturnine  arthritis.1  Why  this  should  be,  I  do 
not  know,  but  the  observations  made  in  my  clinic  are  so  careful 
and  exact,  that  I  cannot  conceive  it  possible  for  such  complica- 
tions of  lead-poisoning  to  be  overlooked.  Perhaps  these  results  do 
not  agree  with  your  observations.  True  gout  is  seldom  seen  here, 
and  that  may  be  the  reason  why  it  is  not  found  in  association  with 
lead-poisoning.     Alcoholism,  however,  is  often  combined  with  it." 


Dr.  Lorimer,  of  Buxton,  in  an  excellent  paper  on  saturnine 
gout,  gives  an  analysis  of  107  cases  which  came  under  his  obser- 
vation.2 He  found  that  this  disorder  usually  appeared  at  an 
earlier  age  than  non-saturnine  gout.  In  70  cases  the  first  attack 
occurred  prior  to  thirty-five. 

1  Archives  Generates  de  Med.,  December  1881. 

2  Brit.  Med.  Jour.,  July  24,  1886. 


DPw    L0R1MER   ON    SATURNINE    GOUT.  1 69 

Heredity  was  less  marked  than  in  non-saturnine  gout,  and 
anasmia  proved  a  notable  feature. 

The  type  of  arthritis  was  asthenic,  the  local  and  constitutional 
features  being  less  intense.  This  he  rightly  attributed  to  the 
associated  cachexia  and  to  the  presence  of  organic  renal  changes. 

Albuminuria  was  present  in  89  cases  permanently,  or  with 
intermission.  The  specific  gravity  of  the  urine  on  an  average 
was  1.012  ;  the  uric  acid  was  diminished,  and,  in  the  last  stages, 
absent. 

Arterial  sclerosis  and  atheroma  were  noted  in  69  cases.  Height- 
ened arterial  tension  and  cardiac  hypertrophy  were  also  observed. 
Pericarditis  was  once  met  with. 

Cutaneous  manifestations  were  seldom  found,  eczema  occurring 
in  one  and  psoriasis  in  another  case.  There  is  a  marked  contrast 
here  with  the  non-saturnine  cases,  where  eczema  is  met  with  in 
about  30  per  cent. 

Gouty  eye-affections  were  infrequent.  One  case  of  iritis  was 
noted.  Neuro-retinitis,  as  a  renal  concomitant,  was,  however, 
found. 

In  2  8  cases  the  joints  of  the  feet  were  implicated ;  in  7  of 
these  the  great-toe  only  was  affected.  In  34  cases  the  joints  of 
the  hands  and  feet  were  both  affected.  In  20  cases  the  joints 
of  the  hands.  In  the  remaining  25  the  knees  also  were  impli- 
cated, and  in  4  the  elbows  suffered. 

Tophi  were  found  in  the  ears  in  2  3  cases. 

Gout  with  lead-impregnation,  Dr.  Lorimer  believes,  attacks  the 
kidneys  chiefly ;  with  alcoholic  excess  the  joints. 

The  following  case  well  exemplified  gout  as  occurring  in  a 
patient  suffering  from  lead-poisoning  : — 

C.  J.  D.,  set.  32,  a  single  woman,  engaged  in  trimming  upholstery,  admitted  under 
my  care,  December  1886.  Very  sallow  and  cachectic  ;  of  small  build.  Had  employed 
a  cosmetic  powder  for  her  face  for  five  years.  This  was  analyzed  and  found  to  be 
carbonate  of  lead.  Marked  Burtonian  line  on  gums  and  buccal  membrane.  Arms 
much  wasted,  double  wrist-drop.  Supinators  unimpaired.  Gubler's  dorsal  tumours 
of  the  hands  well-marked  (caused  by  over-flexion  of  carpus,  deficient  support  of 
extensor  tendons,  and  prominence  of  bones).  Muscles  of  upper  arms  and  scapulae 
affected,  the  deltoids  especially.  Legs,  muscles  much  wasted  and  flabby,  tremors, 
no  rigidity.  Pains  in  muscles  and  bones,  with  much  tenderness  on  pressure.  Both 
knee-jerks  increased.  Slight  ankle-clonus.  Walks  feebly.  Faradic  contractility 
completely  lost  in  extensors  of  thumbs  of  both  hands  ;  much  impaired,  but  not  lost, 
in  other  extensors.  Supinators  react  readily.  Galvanic  irritability  lost  in  muscles 
of  thumb,  the  others  reacting  fairly  well,  except  extensor  communis  digitorum  of  right 
arm.  Electro-sensibility  unimpaired.  Muscles  of  both  legs  react  readily  to  both 
currents.  {Dr.  Steavensons  Report.) — History  of  attacks  of  colic.  Urine  of  rather 
low  sp.  gr.,  with  occasional  traces  of  albumen  and  blood.  Urea  much  diminished. 
Pulse  frequent  and  of  high  tension.     Attacks  of  acute  gout  in  left  great  toe  and 


170      RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 

left  wrist-joints.    Appearance  of  small,  shot-like,  and  movable  subcutaneous  nodules 
over  the  tibiae.1     No  family  history  of  gout  obtainable. 

Great  improvement  in  the  course  of  six  months  under  treatment  by  good  diet, 
warm  baths,  galvanism,  and  large  doses  of  iodide  of  potassium. 


3.— The  Relationship  between  Gout,  Struma,  and 
Tuberculosis. 

I  think  it  may  fairly  be  affirmed  that  gout  and  active  tuber- 
cular disease  are  not  often  found  associated.  It  is,  of  course, 
to  be  borne  in  mind  that  the  former  is,  for  the  most  part,  a 
disorder  of  middle  life,  and  the  latter  one  manifesting  itself 
chiefly  in  the  earlier  decades.  Many  who  sink  under  tubercular 
disease  might,  if  they  were  spared,  eventually  become  gouty. 

In  the  constant  and  inseparable  Mendings  of  diathetic  states 
the  gouty  and  tubercular  must,  and  do,  often  coalesce. 

It  is  not  often  that  gout  is  well-marked  in  persons  distinctly 
tuberculous.  I  have,  however,  met  with  examples,  and  seen 
others,  in  which  struma  and  gout  distinctly  blend,  and  afford 
noteworthy  manifestations  at  different  periods  of  life.2 

Some  of  the  older  writers  described  an  arthritic  or  gouty 
form  of  phthisis,  occurring  chiefly  in  middle  or  late  life  in  both 
sexes,  characterized  mainly  by  tendency  to  copious  haemoptysis, 
slight  muco-purulent  expectoration,  and,  especially,  by  its  slow 
progress  and  tendency  to  cure.  They  also  noted  the  occurrence 
of  cases  in  which  there  was  little  cough  but  much  dyspnoea,  and 
of  others  which  would  now  be  recognized  as  examples  of  chronic 
bronchitis  and  emphysema.  They  laid  stress  upon  the  frequent 
presence  of  cretified  masses  in  the  lungs  of  such  persons.  These 
would  now  be  regarded  as  evidence  not  of  any  specific  gouty 
element,  but  merely  as  indications  of  obsolete  and  healed  tuber- 
cular lesions. 

So  far,  these  signs  afford  proof  of  tendency  to  obsolescence  in 
tubercular  processes  in  the  gouty. 

Lay  cock  described  the  "arthritic  tubercular  cachexia,"  and 
declared  that,  ' '  with  the  taint  of  gout  in  the  ancestral  or  col- 
lateral line,  there  are  always  present  some  of  the  leading  char- 
acteristics of  the  arthritic  diathesis,  namely,  regular  features, 
well-set,  sound  teeth,  and  a  pearly  white  or  florid  complexion. 

1  These  presented  the  characters  of  the  ephemeral  nodules  first  described  by  Ferebl, 
Troisier,  and  Brocq,  and  subsequently  by  Dr.  Barlow,  myself,  and  others,  as  occurring 
in  rheumatic  individuals. 

2  As  pointed  out  by  Paget,  this  co-existence  may  be  found  without  any  modifying 
influence  of  the  one  state  upon  the  other. 


GOUT    AND    STRUMA.  I  7  I 

But  the  lower  jaw  is  usually  contracted,  the  bones  of  the  face 
small,  the  skin  delicately  thin  or  transparent ;  the  neck  elon- 
gated, the  thorax  narrowed,  and  the  heart's  action  feeble  and 
irregular." x  He  noted  the  tendency  to  haemorrhage  in  such 
cases  as  a  precursor  of  the  tubercular  deposit,  due,  as  he  thought, 
to  fatty  degeneration  of  the  pulmonary  vessels ;  also  the  absence 
of  deposit  in  the  lymphatic  glands. 

Gout  and  scrofula,  according  to  Paget,  are  often,  by  inherit- 
ance, so  intermixed  that  the  resulting  condition  can  hardly  be 
analyzed.  In  early  life  strumous  manifestations  most  usually 
prevail,  and,  at  this  period,  little  or  no  token  of  any  gouty  ele- 
ment may  be  apparent.2 

It  is,  therefore,  chiefly  in  later  life  that  evidence  is  afforded  of 
the  coalescence  of  the  two  diathetic  states.  The  observations  of 
Paget  have  shown  that  while  scrofula  may  often  be  outlived,  yet 
manifestations  of  it  may  occur  late  in  life,  and  materially  modify 
ordinary  gouty  processes.  He  tells  of  a  patient  of  gouty  inherit- 
ance, who  in  middle  life  had  inflammation  of  the  tarsus  re- 
sembling acute  gout,  but  the  pain,  stiffness,  and  swelling  did  not 
subside  as  usual  in  due  time.  After  several  months  there  re- 
mained pulpy  swelling  about  the  tarsus,  with  dull  aching,  inutility 
and  wasting  of  the  leg,  and  other  features  quite  characteristic  of 
scrofula.  Treatment  was  required  for  months  with  splints  and 
other  means  inappropriate  for  gout.  A  daughter  of  this  patient 
had  scrofulous  disease  of  the  hip-joint.3  In  such  a  case  the  like- 
ness to  gout  is  manifest  at  the  outset,  but  instead  of  a  transient 
paroxysmal  inflammation,  there  gradually  supervene  the  characters 
of  chronic  scrofulous  arthritis. 

With  the  knowledge  of  specific  bacilli  as  associated  with  tuber- 
cular processes,  it  has  been  sought  to  explain  the  acknowledged 
inhibitory  effect  of  gouty  influence  upon  scrofula  as  due  to  the 
direct  action  of  uric  acid  in  the  blood  upon  these  parasites.  This 
is  the  teaching  of  Lecorche,  who,  with  Dr.  Pye-Smith,  denies  the 
existence  of  all  diathetic  habits  of  body.      I  am  not  prepared  to 

1  Op.  cit.,  p.  102. 

2  The  famous  Dr.  Samuel  Johnson  was  scrofulous  in  early  life,  and  had  a  scarred 
neck.  He  developed  gout  some  years  before  his  death,  and  died  of  gouty  cachexia 
at  the  age  of  seventy-five.  Dr.  Norman  Moore,  in  an  introductury  lecture  on 
pathology,  has  published  the  notes  of  his  post-mortem  examination  by  Mr.  Wilson,  the 
anatomist.  It  shows  that  he  had  the  anatomical  conditions  usually  associated  with 
gout,  chronic  interstitial  nephritis,  and  emphysema  of  the  lungs.  His  attack  of 
hemiplegia,  some  time  before  his  death,  points  to  the  degeneration  of  his  cerebral 
arteries.  He  was  never  very  robust.  As  Boswell  remarked  of  him,  he  possessed 
"an  inherent  vivida  vis,  which  is  a  powerful  preservative  of  the  human  frame." 

3  Op.  cit.,  p.  437. 


172       RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

accept  this  view.  I  recognize  an  antagonistic  influence  of  the 
gouty  upon  the  tubercular  habit,  and  agree  with  those  who  find 
tubercular  processes  checked,  often  for  long  periods,  and  rendered 
obsolete  in  virtue  of  gouty  predisposition.  In  this  country  no 
one  has  more  carefully  studied  this  subject  than  Dr.  James  Edward 
Pollock.1  He,  however,  considers  gout  and  rheumatism  so  closely 
allied  to  each  other  in  their  pathological  development,  that  they 
may  be  considered  together  in  their  influence  on  pulmonary 
tuberculosis,  and  I  regret  that  he  has  not  studied  the  two  dis- 
orders apart  in  this  relationship.  He  quotes  the  views  of  Noel 
Gueneau  de  Mussy  as  to  the  identity  of  the  arthritic  with  the 
tubercular  constitution.  This  author  held  that  in  many  instances 
where  gout  is  believed  to  "overleap"  one  generation  and  come 
out  in  the  next,  the  intermediate  one  was  not  free  from  gouty 
attacks,  which  were  exhibited  in  scrofulous,  and  tubercular  diseases  ; 
and  that  females  manifested  the  inherited  diathesis  in  various 
forms  of  tubercular  disease.  A  distinction  must,  however,  be 
made  between  the  arthritic  habit  and  the  gouty  branch  of  that 
stock. 

There  is  evidence  to  show  alliance  between  tuberculosis  and 
the  rheumatic  branch  of  the  arthritic  stock,2  but  much  less  evi- 
dence to  indicate  a  connection  between  tuberculosis  and  a  truly 
gouty  proclivity.  Dr.  Pollock's  statistics  afford  proof  of  this, 
there  being  many  more  instances  of  associated  rheumatic  disease 
than  of  gout.  He  showed  that  the  male  sex  was  more  affected 
in  this  association,  the  ages  being  from  twenty  to  twenty-five 
years,  while  the  gouty  cases  occurred,  as  might  be  expected,  in 
older  subjects,  from  forty  to  fifty  years  of  age.  In  the  case  of 
rheumatism,  the  question  of  antagonism  is  also  materially  affected 
by  the  coexistence  of  valvular  heart-disease,  which  is  a  recognized 
cause  of  retardation  in  tuberculosis. 

Dr.  Pollock  showed  that  gout  when  developed  in  a  phthisical 
subject  possessed  inhibitory  power  and  checked  the  tubercular 
process,  the  pulmonary  symptoms  being  relieved ;  and  that,  in 
such  cases,  the  disease  was  protracted,  and  a  prognosis  for 
chronicity  was  warranted. 

The  cases  I  have  seen,  and  those  that  have  been  recorded, 
have  been  mostly  in  men  past  middle  life.  Their  lung-symp- 
toms betokened  a  "  quiet  "  form  of  phthisis,  with  progressive 
fibrosis  and  dependent  clubbing  of  fingers  and  toes.      I  exclude 

1  Elements  of  Prognosis  in  Consumption.     London,  1865,  p.  270. 

2  Vide  Dr.  Sutton's  views,  noted  under  head  of  Relation  of  Gout  to  Chronic  Rheu- 
matic Arthritis,  p.  154. 


GOUT  AND    PULMONARY    TUBERCULOSIS.  I  73 

all  cases  with  rheumatic  disease  and  cardiac  complications  from 
this  category,  and  allude  to  purely  gouty  cases.  In  some  cases 
of  associated  gout  and  tuberculosis,  regard  must  be  had  to  the 
special  influence  of  alcoholic  excess,  which  exercises  untoward 
effect  on  the  latter. 

Dr.  Pye-Smith  has  recorded  four  examples  of  pulmonary 
phthisis  occurring  in  truly  gouty  subjects,  all  males,  aged  thirty- 
nine,  forty-eight,  and  sixty  years  respectively — the  age  of  one 
not  being  mentioned.1 

In  the  man.  set.  sixty,  there  were  tophi.  There  was  history 
of  gout  in  two  brothers.  The  urine  was  albuminous,  and  there 
was  haemoptysis.  In  two  others,  attacks  of  gout  occurred  during 
the  progress  of  the  lung-mischief.  In  the  youngest  patient 
there  were,  with  much  uratic  deposit,  very  "bad"  arteries, 
granular  kidneys,  hypertrophied  cardiac  left  ventricle,  and  gastro- 
enteritis, the  latter  causing  death ;  tubercles  in  both  pulmonary- 
apices,  with  vomica  in  right  lung  and  much  cicatricial  tissue. 

In  the  autopsies  of  eighty  cases  of  gout  recorded  by  Dr. 
Norman  Moore,2  pulmonary  tubercle  was  found  six  times  in  men 
whose  ages  varied  from  thirty-four  to  sixty.  It  occurred  in 
all  stages,  from  recent  deposits  to  cavities  and  cretification.  In 
no  case  was  it  the  immediate  cause  of  death,  and  in  none  had  it 
given  rise  to  prominent  symptoms  during  life. 

The  noteworthy  features  of  pulmonary  tuberculosis  as  modified 
by  gout  are,  that  there  is  apparently  more  than  ordinary  tendency 
to  free  hsemoptysis  at  the  outset,  with  tendency  to  occasional 
recurrence  of  it ;  that,  with  acute  exacerbations  of  tubercular 
processes  in  the  lungs,  there  is  a  marked  tendency  to  limitation  of 
the  disease  and  to  its  subsidence,  this  being  followed  by  the  salu- 
tary processes  of  cicatrization ;  and  that,  as  a  result  of  this  mode 
of  tubercular  evolution,  inhibited  by  the  gouty  habit,  such  patients 
exhibit  a  marked  tendency  to  recovery,  or  to  endure  for  a  long 
period.  In  such  cases  there  is  usually  not  far  to  seek  ancestral 
history  of  tuberculosis,  and  the  factor  of  gouty  impress  is  seen, 
so  far,  to  be  of  somewhat  favourable  import,  since  with  each 
arrest  of  tubercular  process  is  afforded  means  for  improving  the 
general  health,  and,  sometimes,  for  promoting  actual  recovery. 
From  whatever  cause,  the  textures  of  the  gouty  appear  to  be 
less  vulnerable  than  those  of  others  in  respect  of  tuberculosis,  but 
the  antagonism  is  far  from  complete,  and  hence  the  tuberculosis 
may  prove  a  fatal  association. 

1  Guy's  Hosp.  Reports,  loc.  jam  cit. 
2  Op.  cit. 


1  74      RELATION    OF    GOUT   TO    OTHER    MORBID    STATES. 

The  following  case  is  illustrative  of  coalescence  of  saturnine 
gout  and  pulmonary  phthisis. 

F.  P.,  aet.  39,  organ-pipe-maker,  came  under  my  care  in  St.  Bartholomew's  Hos- 
pital, November  5,  1888.  His  father  had  suffered  from  gout.  There  was  no  phthisi- 
cal history  obtainable.  Exposure  to  lead-influence  for  twenty-five  years.  No  colic 
or  paralysis.  Blue  line  on  gums.  Winter  cough  five  years.  No  history  of  alcoholic 
excesses.  At  age  of  twenty-three,  first  attack  of  gout  in  left  great  toe-joint.  Many 
subsequent  attacks  in  toes,  insteps,  knees,  wrists,  and  elbows.  Failing  health  and 
wasting  for  twelve  months  past.  Cough  worse  last  five  weeks,  with  much  frothy 
expectoration,  and  night-sweats.  Twelve  days  ago  haemoptysis,  "half  a  cupful;"  to- 
da,j  twice  as  much.  Temperature  990.  Pulse  108,  good  volume  and  tension,  arteries 
not  markedly  thickened.  Respirations  32.  Sputa  in  muco-purulent  pellets,  sour- 
smelling.  Urine  of  sp.  gr.  1010,  void  of  albumen.  Several  nocturnal  micturitions. 
On  examination  of  the  chest  after  a  few  days,  the  physical  signs  indicated  consolida- 
tion and  softening  of  upper  lobes  of  each  lung,  with  vomicEe  more  advanced  on  left 
side.     Some  general  emphj'sema. 

No  indications  of  active  gout,  and  no  tophi  detectible. 

This  man  looked  ten  or  more  years  older  than  his  age.  He  improved  a  little  after 
admission,  but  somewhat  suddenly  failed,  lost  strength,  and  died  on  November  17. 

In  this  case  I  made  a  diagnosis  of  the  supervention  of  pulmo- 
nary tuberculosis  on  chronic  bronchitis  and  emphysema  in  a  man 
the  subject  of  chronic  saturnine  gout.  I  believed  his  kidneys  to 
be  in  a  condition  of  progressive  (granulative)  nephritis. 

The  autopsy  showed  that  both  pulmonary  apices  were  involved 
with  chronic  interstitial  pneumonia,  leading  to  bronchiectasis. 
Numerous  vomicae,  full  of  purulent  matter,  existed  apart  from  the 
bronchial  dilatations,  which  were  fusiform  and  not  expanded. 
Some  scattered  tubercles  were  seen  in  their  neighbourhood.  No 
tubercle  in  the  bronchial  glands.  Dr.  Wynne  examined  portions 
of  the  indurated  lung  and  tubercular-looking  matter,  but  found  no 
evidence  of  true  tubercle. 

There  was  a  good  deal  of  general  emphysema. 

The  heart  was  slightly  hypertrophied  in  its  left,  and  dilated  and 
indurated  in  its  right,  ventricle. 

The  kidneys  were  of  full  size,  very  hard,  containing  cysts  in 
places,  and  granulations  in  parts  of  the  cortices.  No  uratic  streaks 
in  pyramids.      The  capsules  stripped  fairly  well. 

The  articular  cartilages  of  the  right  great  toe-joint  were  en- 
crusted with  uratic  deposit,  and  the  same  was  found  in  the  right 
knee-joint  in  streaks  near  the  edges  of  the  condyles,  and  along 
the  margin  of  the  patella.    The  aorta  was  atheromatous  in  places. 

W.  0.,  set.  65,  came  under  my  care  in  June  1879  f°r  haemoptysis.  He  had  had 
winter-cough  for  four  or  five  years.  The  physical  signs  indicated  consolidation  and 
softening  at  both  pulmonary  apices,  and  there  were  symptoms  of  tubercular  enteritis. 
Fifteen  years  previously,  gout  occurred  in  the  right  great  toe- joint,  and  other  attacks 
had  followed.     His  maternal  grandfather  was  said  to  be  a  "  martyr  to  gout,"  and  his 


GOUT   AND    CANCER.  I  75 

mother  suffered  from  "chalky"  gout.     His  father  lived  to  be  ninety.     The  urine  was 
void  of  albumen.     The  result  of  the  case  is  unknown  to  me. 

S.  J.,  set.  51,  a  butcher,  came  under  my  care  for  haemoptysis  in  June  1883.  He 
had  been  a  free  drinker,  chiefly  of  spirits.  No  gouty  history  known  of  in  his  family. 
First  attack  of  gout  in  left  great  toe-joint  eight  or  nine  years  previously.  Many  sub- 
sequent attacks.  There  were  signs  of  consolidation  and  softening  at  each  pulmonary 
apex,  with  indications  also  of  fibrosis.     The  urine  was  free  from  albumen. 

In  attempting,  as  we  ought,  to  determine  the  ultimate  issue  of 
each  case  of  blended  diatheses,  we  must  discover  how  much  of  each 
prevails,  since  it  is  mainly  the  question  of  the  intensity  or  pre- 
dominance of  one  or  the  other  state  which  must  furnish  the  clue.1 
The  onset  of  pulmonary  phthisis  in  cases  of  chronic  gout  must  be 
sometimes  regarded  as  a  mode  of  degeneration  in  cases  where,  by 
reason  of  alcoholic  intemperance,  the  lungs  become  vulnerable  and 
break  down.  The  progress  of  the  phthisis  is  retarded  in  such 
instances  by  the  remaining  degree  of  inherent  vitality,  and  by  the 
tendency  to  fibroid  change,  which  always  warrants  a  prognosis  for 
chronicity. 


4.— Relationship  between  Gout  and  Cancer. 

The  gouty  are  in  no  way  protected  from  occurrence  of  cancer. 
They  appear  rather  to  be  somewhat  liable  to  it.  In  ten  fatal  cases 
of  gout,  Pye-Smith  records  cancer  in  two  instances  in  men.  In 
one,  aet.  forty-seven,  there  was  cancer  of  the  oesophagus  opening  into 
the  lung  ;  and  in  the  other,  aet.  fifty-nine,  there  was  cancer  of  the 
ribs,  vertebrae,  liver,  &c.  He  speaks  of  its  occurrence  as  uncon- 
nected with  gout,  save  by  its  preference  for  the  same  period  of  life. 

According  to  Paget,  gout  and  cancer  are  often  found  together, 
each  pursuing  its  separate  course,  "  the  cancer  in  one  part,  the 
gout  in  another."  In  treating  of  the  succession  of  constitutional 
diseases,  he  declares  it  not  to  be  rare  to  find  a  patient  who  has 
been  scrofulous  in  early  life,  gouty  in  later  life,  and  finally  the 
subject  of  cancer.  He  relates  the  case  of  a  gentleman  of  seventy- 
five  years  of  age  who  had  psoriasis  for  thirty  years,  and  had  taken 
calomel  for  it  in  grain-doses  daily  for  twenty-five  years,  enjoying 
all  the  time  excellent  general  health.  At  seventy-five,  epithelial 
cancer  appeared,  and  quickly  increased  on  one  little  finger.  After 
its  amputation  there  followed  his  first  attack  of  gout,  a  family 
disease,  with  which  his  brother,  eighty  years  old,  was  at  the  time 
suffering.    He  died  within  a  year  with  cancer  in  his  axillary  glands. 

1  According  to  M.  Baumes,  a  gouty  father  and  a  tuberculous  mother  will  beget  an 
asthmatic  child,  the  father  furnishing  a  predisposing  general  cause,  the  mother  a 
predisposing  local  cause. 


176      RELATION   OF    GOUT    TO    OTHER   MORBID    STATES. 

Charcot  noted  at  the  Saltpetriere  Hospital  that  women  with 
Heberden's  nodes  were  rather  apt  to  be  the  subject  of  cancer  of 
the  breast  and  womb.  This  is  of  interest  in  respect  of  gout,  which 
is  certainly  the  cause  of  some  forms  of  these ;  and  in  one  such  case 
I  met  with  cancer  of  the  liver,  and  discovered  uratic  deposits  in 
association  with  the  digital  nodes.  I  had  a  well-marked  case  of 
tophaceous  gout  under  my  care  in  a  woman,  get.  circ.  fifty-five, 
who  died  of  cancerous  tubera  in  the  liver. 

William  Budd  recorded  a  case  of  cancer  of  the  penis,  with  de- 
posits in  the  liver  and  lungs,  in  a  man  of  sixty-eight,  who  was  the 
subject  of  true  gout  with  tophi.1 

Three  examples  of  cancer  of  the  stomach  associated  with  gout 
are  related  by  Lecorche,  one  in  a  man  ast.  fifty,  one  in  a  man  set. 
fifty-five,  and  the  third  also  in  a  man  ast.  sixty-three. 

In  France,  cancer  has  been  thought  to  be  especially  frequent 
in  persons  of  arthritic  predisposition.  Bazin,  Cazalis,  and  Verneuil 
have  maintained  this ;  but  the  association  has  not  been  espe- 
cially noted  in  this  country,  and  my  colleague,  Mr.  Butlin,  tells 
me  that  he  has  not  been  struck  with  such  a  coincidence  while 
studying  on  the  broadest  basis  the  whole  subject  of  cancerous 
disease. 

Respecting  the  influence  of  gouty  habit  on  cancer,  the  opinion 
of  Paget  may  be  noted,  to  the  effect  that  the  latter  is  apt  to  be 
attended  with  more  pain  than  is  usual,  severe  paroxysmal  pain, 
and  that  cancers  in  the  gouty  are  liable  to  inflammations  of  their 
substance. 

The  occurrence  of  cancer  of  the  gall-bladder  may  be  noted  in 
connection  with  the  prolonged  irritation  of  biliary  calculi,  which 
are  not  infrequent  in  persons  of  gouty  inheritance  and  habit,  and 
especially  in  women. 

5.— Relationship  between  Gout  and  Syphilis. 

With  the  more  accurate  knowledge  of  the  manifestations  of 
gout  and  of  syphilis  that  has  been  attained  of  late  years,  has  also 
come  more  certain  knowledge  of  the  mutual  influences  of  these 
two  disorders. 

In  this  case,  as  in  that  of  the  relations  between  gout  and 
struma,  it  must  be  noted  that  the  early  manifestations  of  syphilis 
occur  earlier  than  those  of  gout ;  but  even  from  the  earliest  periods 
a  modifying  influence  may  be  observed  in  some  cases. 

And,  first,  it  may  be   stated  that  there   appears  to   be   not 

1  Lancet,  185 1,  p.  482. 


GOUT    AND    SYPHILIS.  I  J  J 

infrequently  in  the  goutily  disposed  a  special  susceptibility  to 
the  poison  of  gonorrhoea,  whereby  they  surfer  more  readily  and 
intensely  than  others.  It  is  in  such  persons  that  there  is  special 
tendency  to  arthritis,  so-called  gonorrhceal  rheumatism,  and  to 
the  eye-troubles  often  associated  therewith.  It  would,  perhaps, 
be  more  correct  to  affirm  that  persons  of  the  arthritic  diathesis 
thus  readily  suffer,  for  either  rheumatic  or  gouty  antecedents 
and  peculiarities  may  be  traced  in  the  majority  of  cases  of  this 
nature. 

It  is  still  a  vexed  question  whether  conjunctival  blenorrhoea 
is  a  result  of  direct  inoculation  or  not.  The  weight  of  evidence 
is  in  favour  of  the  non-contagious  view.  Such  infectivity  as  is 
here  conceivable  can  hardly  be  assigned  as  the  cause  of  sclero- 
titis, which  is  not  infrequently  associated  with  gonorrhoea  in 
the  gouty.  It  hardly  admits  of  doubt  that  cases  of  gonorrhoea 
followed  by  arthritis  and  sclerotitis  occur  most  often  in  persons 
of  the  arthritic  diathesis,  and  chiefly  in  the  gouty  line  of  it. 
There  is  evidence  to  show  that  urethritis  may  occur  in  the  gouty 
after  pure  intercourse,  where  there  may  be  hardly  more  than 
leucorrhoea  as  the  excitant,  and  that  such  urethritis  may  again 
and  again,  when  it  occurs,  induce  articular  and  eye-symptoms 
of  the  type  of  so-called  gonorrhceal  rheumatism. 

Such  a  sequence  is  very  significant  of  gouty  predisposition, 
exhibiting  the  special  vulnerability  just  referred  to,  and  may 
be  met  with  in  men  who  have  had  no  regular  gout. 

With  respect  to  the  specific  poison  of  lues,  it  is  now — and  I 
entertain  myself  no  doubt  on  the  matter — fairly  well- recognized 
that  its  fruits  will  vary  according  to  the  tissue-soil  on  which  it  is 
implanted ;  so  that  varying  manifestations  may  be  looked  for 
according  as  the  patient  is  strumous  or  gouty,  or  degenerate  by 
alcoholic  and  other  excess. 

In  the  gouty  there  is  reason  to  believe  that  syphilis  tends  to 
evoke  lesions  of  the  skin  akin  to  those  which  are  more  common 
in  such  persons,  especially  the  squamous  class,  and  renders  such 
patches  rather  more  itchy  and  irritable  than  they  are  in  other 
subjects. 

There  is  no  evidence  that  the  primary  lesions  are  in  any  way 
influenced  by  gouty  predisposition. 

The  tertiary  symptoms,  as  occurring  later  in  life,  are  more  apt 
than  any  to  be  modified  in  the  gouty. 

Thus,  we  meet  with  the  various  forms  of  psoriasis  of  the  tongue, 
or  leucoma,  and  with  chronic  ostitis  and  synovitis  rebellious  to 
treatment.      Persistent  neuralgia  and  myalgia  may  occur  in  those 

M 


178   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

who  are  both  gouty  and  syphilitic.  M.  Lecorche  is  inclined  from 
his  observations  to  believe  that  the  gouty  habit  confers  some 
immunity  from  the  manifestations  of  syphilis,  but  his  cases  afford 
little  support  to  such  a  doctrine. 

Intractable  gleet  is  sometimes  dependent  on  gouty  habit  of 
body,  and  the  same  may  be  affirmed  of  certain  urethral  strictures, 
which,  according  to  Paget,  may  be  likened  to  the  indurative 
changes  met  with  in  the  corpus  cavernosum  or  in  the  palmar  fascia. 

Mr.  Hutchinson  declares  that  he  has  never  seen  any  reason  to  believe  that  gout- 
tendencies  modify  syphilis.  "Syphilis,"  he  states,  "  varies  very  remarkably  in  rela- 
tion to  the  state  of  the  patient,  but  it  seems  to  me  more  a  matter  of  inexplicable 
idiosyncrasy  than  of  anything  which  can  be  assigned  to  complication  with  other  dia- 
theses. It  is  sometimes  very  difficult  to  determine  between  what  is  gout  and  what 
syphilis  in  cases  where  bones  and  joints  suffer,  and  especially  in  cases  of  threatened 
ataxy  after  syphilis.  Usually,  I  believe,  gouty  persons  have  syphilis  just  like  others, 
and  syphilitic  patients  have  gout  in  the  same  way.  I  cannot  see  any  reason  to 
believe  that  the  one  effects  any  important  modification  of  the  other."  1 

6.— Relation  of  Gout  to  Diabetes  and  Glycosuria. 

No  fact  in  practical  medicine  is  better  established  than  the 
dependence  of  a  variety  of  glycosuria  on  the  gouty  habit  of  body. 
The  indications  of  gout  are  seldom  far  to  seek  in  the  cases  now 
referred  to.  There  may,  or  may  not,  be  history  of  paroxysmal 
articular  attacks.  The  family  history  is,  as  a  rule,  plainly  indica- 
tive of  the  predominance  of  this  diathesis.  Thus,  with  gouty 
ancestry  or  parentage,  there  may  occur  in  a  family  certain  mem- 
bers who  develop  true  gout,  and  others  diabetes.  Some  may  be 
the  subject  of  megrim,  of  obesity,  of  biliary  lithiasis,  urinary  gravel, 
eczema,  asthma,  or  other  forms  of  masked  gout.  These  relation- 
ships have  been  dogmatically  insisted  on  in  the  French  school ; 
my  own  experience  amply  confirms  them,  and  a  study  of  them  is 
of  the  highest  import  and  significance. 

It  has  long  been  known  that  there  is  some  connection  between 
diabetes  and  the  gouty  diathesis.2      A  careful  study  of  many  cases 

1  Private  letter. 

2  Stosch  in  1828  and  Naumann  in  1829  are  credited  with  the  earliest  mention  of 
these  cases  in  Germany. 

It  seems  not  unlikely  that  reference  is  made  to  some  instances  of  diabetes  of  the 
class  here  discussed  by  Trotter,  who  remarks,  "  The  majority  of  persons  whom  I 
have  known  subject  to  diabetes  were  lovers  of  the  bottle.  I  suspect  that  many 
drunkards  have  this  complaint  upon  them  without  taking  notice  of  it,  and  that  it 
conies  and  goes,  without  creating  alarm,  just  as  they  happen  to  live  regular  or  other- 
wise."— An  Essay,  <L-c,  on  Drunkenness  (D.  M.  I.,  Edin.  17SS),  by  Thomas  Trotter, 
M.D.     London,  1804. 

Thomas  Willis,  in  1674,  attributed  diabetes  to  the  "  guzzling  of  strong  wines, 
sadness,  or  long  sorrow." 

Rayer  is  alleged  (by  Charcot)  to  have  noticed  that  gout  changes  into  diabetes.  I 
cannot  find  any  proof  of  this  in  his  Traite  des  Maladies  des  Reins,  1839. 


GLYCOSURIA.       SACCHARINE    DIABETES.  I  79 

of  diabetes  and  of  gout  cannot  fail  to  lead  the  clinical  observer  to 
believe  in  such  a  connection.  It  is  remarkable,  therefore,  to  find 
that  but  few  authors,  treating  respectively  of  these  disorders,  allude 
to  this  relationship.  Where  the  subject  has  been  noted,  there 
has  been  but  little  light  thrown  upon  it,  and  indeed  it  is  one  of 
extreme  abstruseness. 

It  may  be  well,  in  the  first  place,  to  relate  some  of  the 
observations  that  have  been  already  made,  and  it  is  interesting  to 
note  that  the  subject  has  been  more  often  approached  by  writers 
from  the  diabetic  than  from  the  gouty  side. 

Prout x  was  amongst  the  first  to  note  that  glycosuria  was 
common  amongst  dyspeptic  and  gouty  individuals,  and  that  hun- 
dreds passed  years  of  their  lives  with,  this  symptom  more  or 
less  constantly  present,  who  were  quite  unaware  of  it  till  the  quan- 
tity of  urine  became  increased.2 

Prout's  large  field  of  experience  led  him  to  classify  diabetic 
patients  into  two  classes  (and  others  have  followed  him  in  this), 
the  spare  and  feeble  type,  and  the  robust  and  corpulent  type, 
and  upon  this  classification  we  shall  find  that  we  may  best  illus- 
trate what  is  certainly  known  of  this  subject.  The  connection 
between  the  gouty  habit  and  glycosuria  is  shown  in  two  well- 
marked  cases  related  by  Prout,  in  one  of  which  red  gravel,  and  in 
the  other  renal  calculus  occurred.  He  also  gives  instances  of 
glycosuria  in  corpulent  women,  and,  so  far  as  I  know,  was  the 

1  On  Stomach  and  Renal  Diseases,  4th  edit.,  p.  34,  1843. 

2  Opinions  still  differ  as  to  the  "  unity  "  of  diabetes.  On  the  one  hand,  the  milder 
and  intermitting  forms  of  the  disease,  and  the  temporary  and  slight  degrees  of 
saccharine  impregnation  in  the  urine,  seem  to  favour  the  view  that  there  is  a  separate 
disorder,  or  even  a  series  of  disorders,  to  which  the  term  glycosuria  is  best  adapted. 
On  the  other  hand,  the  fact  that  these  forms  of  glycosuria  sometimes  distinctly  pass 
into  true  and  essential  diabetes  appears  to  warrant  the  opinion  of  the  unity  of  the 
disease,  the  glycosuric  cases  being  merely  regarded  as  mildly  diabetic. 

My  own  opinion  inclines  to  the  latter  view.  I  cannot  admit  that  any  localized 
perverted  chemical  relations  can  habitually  proceed  in  the  body  without  the  inter- 
vention of  the  directing  influence  of  the  central  nervous  system. 

The  fact  that  irritation  of  the  liver  by  food  of  injurious  quality  sometimes  induces 
glycosuria,  is  readily  explained  by  reflex  nervous  action  through  the  medulla  oblongata, 
and  may  be  termed,  as  it  has  been,  hepatic  glycosuria ;  but  if  clinical  experience, 
shows  that  such  disorder  eventuates  in  ordinary  diabetes,  with,  probably,  damaged 
nerve-centres,  I  think  the  unity  of  the  disease  fairly  proven.  There  are,  without 
doubt,  varieties  of  diabetes  in  relation  to  causation,  and  of  these  are  the  symptomatic, 
or  diathetic,  cases.  In  many  of  them,  if  the  primary  cause  can  be  removed,  the  dis- 
order is  arrested.  Amongst  these  varieties  is  to  be  placed  that  in  relation  to  arthri- 
tism.  Such  cases  as  those  recorded  by  Lancereaux  and  others,*  where  the  disease 
was  obviously  due  to  destruction  of  the  pancreas,  constitute  another,  and  certainly 
rare,  variety  of  diabetes. 

*  Bulletin  dt  I' Academic  de  Medecine,  1877,  2e  se'rie,  tome  vi.  p.  1215. 


l8o   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

first  to  show  that  pruritus  vulvas  was  often  a  symptom  of  diabetes 
in  women. 

Prout  further  insisted  upon  the  fact  that  in  favourable  cases  of 
diabetes  the  quantity  of  uric  acid  passed  was  very  considerable, 
and  he  traced  the  earliest  symptoms  of  the  onset  of  glycosuria 
back  to  the  time,  in  any  given  case,  when  the  urine,  which  was 
formerly  continuously  turbid  on  cooling,  began  to  be  clear,  or  to 
a  definite  attack  of  gout  or  rheumatism.  He  stated  that  this 
change  sometimes  occurred  abruptly,  the  diabetic  symptoms 
gradually  supervening.  To  such  cases  he  applied  the  term  "  latent " 
diabetes. 

About  thirty  years  ago,  Dr.  Bence  Jones  wrote  upon  this 
subject  under  the  title  of  "  Intermitting  Diabetes," l  relating 
seven  cases  in  which  alternations  of  glucose  and  excess  of  urates 
occurred. 

In  1854,  Dr.  W.  Gairdner  wrote  that  he  had  long  surmised 
that  saccharine  impregnation,  not  amounting  to  any  diabetic 
tendency,  was  attendant  on  various  phases  of  gout.2 

Claude  Bernard3  referred  to  cases  of  alternating  diabetes  in 
which  attacks  of  gout  or  rheumatism  replaced  the  glycosuria,  the 
urine  being  charged  with  uric  acid : — "  On  voit  quelquefois  des 
malades  goutteux  dont  les  urines  contiennent  beaucoup  d'acide 
urique,  presenter  tout  a  coup  le  symptome  des  diabetiques,  et  les 
urines  se  charger  de  sucre,  c'est-a-dire  la  goutte  se  changer  en  un 
acces  de  diabete." 

Laycock4  taught  that  the  gouty  diabetic  patient  did  not  waste 
nor  become  tuberculous. 

March al  (de  Calvi)  discussed  this  subject  very  fully  in  his 
excellent  work  on  diabetes.5  His  belief  was  that  gout  and 
diabetes  (in  its  most  common  form)  are  only  diffei'ent  expressions 
of  the  same  morbid  state,  or  holopathy,  sub-diatheses  of  the  uric 
acid  diathesis.  He  regarded  uric  or  gouty  diabetes  as  the  common 
variety  and  the  type  of  diabetes,  and  gave  his  reasons  for  this 
opinion  at  length.  His  theory  was,  that  when  the  uric  acid 
diathesis  affected  the  solids,  it  gave  rise  to  gout  or  rheumatism, 
and  when  it  affected  the  blood  itself,  it  set  up  diabetes ;  and  that 
diabetes  was  nothing  else  than  gout  in  the  blood. 

In  reviewing  Marchal's   theory,  Charcot  states   that  his   con- 

1  Medico-Chirurgieal  Trans.,  vol.  xxxvi.,  1853,  p.  403. 

2  Op.  eit.,  p.  127. 

3  Lecons  de  Physiologie  Experimentale.     Paris,  1855,  p.  429. 

4  Lectures  on  Pract.  of  Physic.     Edinburgh.  1862. 

5  Recherches  sur  les  Accidents  diabetiques  et  Essai  d'une  Theorie  generale  du  Diabete. 
Paris,  1864. 


GLYCOSURIA.       SACCHARINE    DIABETES.  iSl 

elusion  agrees  with  previous  observations  and  with  actual  facts  ; 
but  he  believes  that  Marchal  extended  the  influence  of  this  form 
of  diabetes,  and  that  of  the  uric  acid  diathesis  in  general,  too  far, 
his  views  not  being  applicable  to  the  favoured  classes  of  society, 
at  least  in  France.  Lecorche  x  thus  alludes  to  Marchal's  theory  : — 
"  On  aurait  tort  de  vouloir  donner  a  ce  terme  specifique  de  diabete 
goutteux  une  comprehension  trop  grande,  et  surtout  de  regarder 
tous  les  diabetes,  comme  fatalement  lies  a  la  grande  diathese 
urique,  ainsi  que  l'a  fait  Marchal." 

The  question  of  this  relationship  had  much  interest  for  Trousseau, 
who  discussed  it  in  his  lectures  both  on  gout  and  on  diabetes. 
He  fully  recognized  the  alternation  of  a  diabetic  with  a  gouty 
state,  but  he  differed  from  Prout  in  that  he  did  not  consider  the 
glycosuria  to  constitute  the  disease  known  as  saccharine  diabetes. 
He  described  an  intermittent  diabetes  occurring  only  after  meals, 
sometimes  becoming  continuous,  however,  and  a  periodic  form  in 
which  glycosuria  existed  at  distinct  periods  and  at  long  intervals  ; 
and  believed  that  these  were  perhaps  only  different  forms  of  true 
diabetes. 

Garrod  has  made  some  interesting  observations  on  the  relation 
of  gout  and  diabetes,  showing  that  the  supervention  of  the  latter 
in.  any  given  case  tends  to  check  the  expression  of  obvious  gouty 
symptoms,  the  increased  urinary  water  carrying  off  uric  acid  and 
other  solids.  In  cases  where  the  gout  has  continued,  he  has  not 
found  much  increase  of  urinary  secretion,  although  there  may 
have  been  much  glucose ;  hence  he  believes  that  the  uric  acid 
may  not  have  been  completely  thrown  out.  He  quotes  one  well- 
marked  case  in  a  male  set.  sixty,  who  had  gout  yearly  and  half- 
yearly  after  his  forty-eighth  year.  Diabetes  suddenly  supervened, 
and  no  gout  appeared  for  four  years.  The  diabetes  was  afterwards 
checked,  the  specific  gravity  of  the  urine  falling  from  1.04 1  to 
1.02 1.  Later,  slight  gout  followed  on  an  attack  of  bronchitis. 
Garrod  has  known  of  several  similar  cases,  as  also  of  instances 
where  patients  have  lost  all  traces  of  gravel  and  calculi  on  the 
supervention  of  diabetes. 

Charcot2  has  recognized  the  relationship,  which,  he  states,  is 
regulated  by  still  unknown  laws,  and  gives  particulars  of  a  case. 
He  also  shows  in  a  tabular  form  how  gout,  scrofula,  diabetes,  and 
corpulence  were  found  in  many  members  of  one  family,  and 
gives  in  another  table  the  following  particulars  : — 

1  Traiti  du  Diabete,  p.  273.     Paris,  1877. 

2  Lecons  sur  les  Maladies  des  Vieillards  et  les  Maladies  chroniques,  p.  98.     Paris, 

1868. 


1 82       RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

First  son  had  gravel. 

_,  „  .       Second  son,  diabetes. 

±  ather  gouty  <  mi  .  n  ,      .  , ,  .  . 

D       J      lhird  son,  gout,  phthisis. 

I  Daughter,  gravel. 

He  believes  that  the  frequency  of  this  relationship  varies  accord- 
ing to  the  sphere  of  the  observer. 

Sir  William  Gull  tells  me  that  he  has  long  observed  the  de- 
pendence of  glycosuria  upon  a  gouty  state,  and  remarks  that  such 
cases  are  not  uncommonly  discovered,  but  that  they  do  not  discover 
themselves.  He  thinks  they  are  not  regular  cases  of  diabetes, 
though  they  may  drift  into  the  confirmed  malady.  They  occur 
mostly  in  men,  and  cardiac  and  renal  changes  may  be  associated 
with  the  condition. 

Under  the  head  of  "  Milder  Types  of  Diabetes,"  Sir  William 
Roberts  describes  a  group  of  cases  in  which  glycosuria  is  found  in 
persons  advanced  in  years,  of  full  habit,  where  there  is  moderate 
conservation  of  flesh  and  strength,  slight  diuresis,  small  amount  of 
sugar  passed,  abundance  of  uric  acid  deposit,  together  with  the 
frequent  occurrence  of  gout.  The  sugar,  he  states,  is  sometimes 
present  for  years,  varying  greatly  in  quantit}^,  and  sometimes 
intermitting.1 

In  his  article  on  diabetes  in  Reynolds'  "  System  of  Medicine," 
Dr.  Lauder  Brunton  remarks  that  the  affection  is  often  seen  in 
those  of  gouty  habit,  and  that  in  such  patients  the  disorder  may 
exist  for  a  considerable  time  without  producing  much  apparent 
effect  upon  the  general  health. 

Dr.  Dickinson2  suggests  that  there  is  a  form  of  glycosuria  which 
is  primarily  hepatic.  "  It  is,"  he  remarks,  "  slight  and  transient, 
and  without  much  diuresis.  It  occurs  in  full-fed,  gouty,  and 
plethoric  people,  whose  urine  is  loaded  with  uric  acid  or  lithates. 
In  this  form  of  glycosuria  the  constitutional  symptoms  of  diabetes 
are  mostly  absent." 

Lecorche 3  observes  in  his  classical  work  on  diabetes  that  "  of 
all  diathetic  glycosurias,  the  gouty  and  rheumatic  are,  without 
doubt,  the  most  important." 

Of  this  variety  of  diabetes,  he  writes,  that  it  is  often  preceded 
by  intermittent  glycosuria,  which  is  in  intimate  relation  to  attacks 
of  gout.  Sometimes  sciatica  and  gravel  are  the  gouty  indica- 
tions. Diabetes,  once  declared,  does  not  materially  differ  from  the 
ordinary  form  of  the  malady.      At  first  intermittent,  it  does  not 

1  On  Urinary  and  Renal  Diseases,  2nd  edit.,  p.  258.     London,  1878. 

2  Diseases  of  the  Kidney,  Part  i.,  Diabetes,  p.  99.     London,  1875. 

3  Op.  cit.,  p.  522. 


GLYCOSURIA.       SACCHARINE    DIABETES.  IOj 

become  continuous  till  after  a  certain  lapse  of  time,  and  even  then 
exacerbations  which  are  only  explicable  by  the  peculiar  diathesis 
are  apt  to  occur.  The  gouty  symptoms  may  be  little  pronounced, 
but  there  is  history  of  strong  hereditary  tendency,  and  there  may 
be  coincidence  of  neuralgia, — facial,  sciatic,  and  lumbar, — and  of 
neuroses,  such  as  asthma  and  hemicrania.  Dyspepsia,  nephritic 
colic,  pyelitis,  and  hasmorrhoids  are  sometimes  associated.  Le- 
corche  further  notes  that  there  is  but  slight  polyuria,  and  that 
the  amount  of  glucose  varies  from  300  to  500  grains  in  the  pint, 
red  gravel  being  also  common  in  the  urine.  The  glycosuria  may 
persist  indefinitely  without  becoming  transformed  into  diabetes. 

Lancereaux  believes  firmly  in  the  relation  between  the  arthritic 
diathesis  and  diabetes.  "  L'obesit^,  le  diabete  gras,  la  gravelle 
urique,  et  la  goutte,  forment  une  premiere  serie  de  processus 
morbides,  qui  se  rencontrent  successivement  ou  simultanement 
chez  un  meme  individu,  dans  une  meme  famille,1  se  succedent  par 
heredite,  et  precedent  d'une  meme  condition  pathologique,  l'insuffi- 
sance  des  combustions.  Un  lien  etroit  de  parente  reunit  par 
consequence  ces  etats  pathologiques,  et  les  rend  inseparables." " 

M.  Lasegue  describes  cases  of  imperfect  gout  becoming  cases 
of  incomplete  diabetes  in  certain  individuals,  a  single  attack  of 
bastard  gout  provoking  a  transitory  diabetes. 

In  a  series  of  600  cases  of  diabetes  treated  by  Dr.  R.  Schmitz 
of  Neuenahr,4  he  states  that  in  forty-five  subjects  diabetes  was 
directly  attributable  to  gout,  and  its  origin  to  the  injurious  in- 
fluence exerted  upon  the  nervous  system  by  the  fact  of  the 
blood  being  poisoned  by  uric  acid.  The  gouty  symptoms  had 
existed  in  the  most  varied  forms  long  before  the  appearance  of 
the  diabetes  in  all  the  cases. 

With  respect  to  obesity,  he  found  it  most  conspicuous  in  thirty- 
five  of  the  whole  number,  and  increase  of  it  occurred  in  some 
cases.  In  forty-six  cases  there  was  very  little  loss  of  corpulency. 
It  is  probable  that  many  of  these  instances  presented  the  gouty 
form  of  the  disorder. 

Dr.  Ord 5  has  called  attention  to  cases  of  this  nature.  In 
an   analysis   of  twenty-two   instances   of  glycosuria  occurring  in 

1  "Deux  freres  que  je  soigne  en  ce  moment  sont,  l'un  obese  et  diabetique,  l'autre 
graveleux  et  goutteux.     Les  faits  de  ce  genre  sont  relativement  communs." 

2  TraiU  de  V Herpetisme,  p.  282.     Paris,  1883.  3  Private  communication. 

4  Dr.  Schmitz  does  not  give  the  nationality  of  his  patients  in  detail.  Of  his  600 
cases  420  occurred  in  Germans  and  180  in  foreigners.  In  common  with  other  obser- 
vers, he  met  with  a  large  number  of  cases  amongst  Jews,  there  being  93  instances. 
(Paper  read  before  Medical  Society  of  London,  October  30,  1882,  for  the  author  by 
Dr.  Sedgwick.)     Lancet,  November  4,  1882,  p.  777. 

5  Brit.  Med.  Journal,  November  25,  1882,  p.  1041. 


184      RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 

persons  fifty  years  of  age  and  upwards,  where  the  disease  in 
no  case  merited  the  term  of  diabetes,  as  commonly  applied,  he 
found  the  disorder,  which  he  considered  reduced  to  the  rank 
of  a  symptom  of  other  troubles,  associated  with  four  condi- 
tions of  importance: — (1.)  Nervous  disorder,  either  as  cause  or 
as  concomitant;  (2.)  Gout;  (3.)  Errors  of  diet,  over-eating  and 
over-drinking ;  and  (4.)  Albuminuria.  In  eight  cases  out  of  the 
twenty-two  there  was  gout,  and  in  one  case  rheumatoid  arthritis 
of  twelve  years'  duration.  Albuminuria  existed  in  ten  cases, 
associated  with  gout  in  four.  In  the  majority  of  the  cases  there 
was  little  or  no  emaciation. 

Dr.  Ord  declares  for  the  nervous  origin  of  the  glycosuria  either 
as  a  central  or  a  reflex  disorder,  and  ingeniously  offers  an  explana- 
tion for  the  intermittent  form  of  the  symptom  in  the  gouty,  com- 
paring the  disappearance  of  the  sugar  to  that  which  occurs  in 
diabetes  during  intercurrent  inflammations,  the  glycosuria  being, 
perhaps,  "  a  phenomenon  of  the  same  class  as  gouty  inflammation 
of  joints,  an  active  byperaemia  set  going  in  part  of  the  gouty  pro- 
cess ;  set  going  in  relation  to  irritation  excited  in  the  liver  by 
dietary  errors  or  other  causes,  just  as  inflammation  of  a  joint  is 
set  up  by  a  wrench  or  by  over-exertion  ;  that  it  may,  in  fact,  be 
taken  as  meaning  '  gout  of  the  liver.'" 

Having  now  quoted  the  opinions  of  various  clinical  authorities 
upon  the  existence  of  a  relation  between  diabetes  and  the  arthri- 
tic diathesis,  I  pass  on  to  give  what  evidence  I  can  upon  the 
subject.  It  must  be  at  once  obvious  that  this  is  a  purely  clinical 
question,  one,  in  the  primary  stages  of  the  inquiry,  at  all  events, 
upon  which  neither  the  physiologist  nor  the  chemist  can  shed  any 
light.  Given  sugar  in  the  urine,  the  problem  is  to  find  its  clinical 
significance,  and  its  relation,  if  any,  to  some  known  diathetic  state. 

It  is  obvious  that  if  the  diagnosis  of  a  diathetic  diabetes  be 
made,  the  line  of  treatment  will  vary  accordingly  in  virtue  of  the 
special  relationship  established.  Such  treatment  may  possibly  be 
only  temporarily  applicable  with  prospect  of  benefit,  since  cases 
of  glycosuria,  dependent  originally  upon  diathetic  states,  tend 
sometimes,  if  neglected,  to  become  simple  instances  of  essential  or 
confirmed  diabetes. 

It  may  be  truly  affirmed  that  the  relationship  now  under  dis- 
cussion should  be  better  studied  in  England  than  in  any  other 
country.  If  it  be  the  case,  as  I  firmly  believe  it  is,  that  more 
gouty  disease  prevails  in  England  than  elsewhere,  the  cases  illus- 
trating the  connection  of  glycosuria  and  gout  call  for  exposition 
at  the  hands  of  English  physicians. 


GLYCOSURIA.       SACCHARINE    DIABETES.  185 

The  question  has,  however,  received  a  good  deal  of  attention 
both  in  France  and  Germany,  partly,  it  may  be,  because  the 
wealthier  classes  of  sufferers  from  this  country  have  sought  relief 
at  various  French  and  German  Spas,  and,  hence,  a  large  mass  of 
material  has  been  placed  in  the  hands  of  physicians  who  have  not 
in  their  own  countries  many  opportunities  for  this  particular  line 
of  study  amongst  their  compatriots. 

It  is  important  to  note  that  it  has  long  been  held  that  there 
is  a  positive  antagonism  between  diabetes  and  gout.  Scudamore 
believed  that  diabetes  was  more  frequently  met  with  in  Scotland 
than  in  England,  and  conceived  that  the  dietetic  habits  of  the  two 
peoples  explained  the  prevalence  of  gout  in  the  southern,  and  of 
diabetes  in  the  northern  division  of  the  kingdom.1  The  same 
opinion  has  also  been  expressed  with  respect  to  Ireland,  where 
true  gout  is  most  rarely  met  with,  and  diabetes  not  infrequently. 

It  has  also  been  observed  that  gouty  symptoms  in  a  given  case 
vanish  as  diabetic  symptoms  supervene  ;  hence,  another  reason 
why  an  antagonism  has  been  assumed.  Garrod  has  afforded  an 
ingenious  explanation  of  this  clinical  fact  by  supposing  that  the 
increased  discharge  of  water  from  the  system  washes  out  the 
accumulated  and  superfluous  solid  matters  from  the  blood. 

The  presence  of  sugar  in  the  urine  has  now  attached  to  it 
smaller  importance  than  was  formerly  the  case.2  This  arises  from 
the  systematic  and  careful  examination  of  this  secretion  which  is 
now  made  in  every  grave  case  of  disease,  and  it  has  been  found 
that  in  elderly  people  of  both  sexes  a  little  glucose  is  often  pre- 
sent, even  when  no  noteworthy  symptoms  lead  to  suspicion  of  its 
presence,  or  of  any  serious  injury  to  the  health.  It  is  found,  too, 
that  the  sugar  in  such  cases  is  intermittent  in  its  appearance, 
being  sometimes  replaced  by  excess  of  urea,  and  of  uric  and  oxalic 
acids.  Thus,  there  is  commonly  an  alternation  in  the  respective 
presence  of  uric  acid  and  glucose.  Sometimes  uric  acid  and 
urea  are  in  excess  together  with  sugar. 

In  many  instances  of  glycosuria  which  may  be  relegated  to  this 
class,  the  symptom  would  appear,  as  Dr.  Pavy  points  out,  to  be 
little  more  than  a  measure  of  the  digestive  incapacity  for  amy- 
laceous and  saccharine  food.  There  is  a  limited  power  of  assimila- 
tion, varying  infinitely  in  different  cases,  and  at  different  periods 
of  the  patient's  life.  The  physiological  capacity  likewise  varies 
in  this  direction  at  different  hours  of  the  day.  This  fact  is  note- 
worthy, and  although  forming  a  prominent   feature  in  all  cases 

1  Op.  cit.,  p.  74. 

2  Brucke  and  Bence  Jones  found  -^  grain  per  ounce  normally  present  in  urine. 


1 86       RELATION    OF    GOUT   TO    OTHER   MORBID    STATES. 

of  diabetes,  is  of  especial  interest  in  relation  to  the  gouty  cases, 
since  other  forms  of  digestive  incapacity  exist  in  gout,  which 
forbid  the  use  altogether,  or  in  limited  quantity,  of  certain  articles 
of  meat  and  drink.  It  will  be  shown  subsequently  that  what  is 
bad  for  gout  is  also  bad  for  the  diabetes  associated  with  it. 

It  would  be  manifestly  wrong  to  suppose  that  in  all  the  cases 
of  mild,  latent,  or  intermittent  diabetes  a  gouty  taint  is  to  be 
suspected.  In  many  of  the  patients  belonging  to  the  class  of 
fat  diabetics,  I  have  failed  to  find  any  history  or  indications  of 
arthritism.  In  a  certain  proportion,  however,  evidence  is  not  far 
to  seek. 

In  looking  over  my  notes  of  a  large  number  of  cases  of  well- 
marked  gout,  I  find  that  glycosuria  is  of  extreme  infrequence  ; 
and  I  argue  from  this  that  the  more  accentuated  and  complete 
the  gout,  the  less  likelihood  there  is  of  undue  saccharine  forma- 
tion. The  type  of  case  in  which  glycosuria  is  apt  to  occur  is 
that  of  irregular  or  incomplete  gout.  This  does  not,  however, 
hold  good  for  cases  of  rheumatic  type,  since  in  these  the  joint- 
affection  appears  to  be  present  in  a  severe  degree  together  with 
the  glycosuria. 

It  is  not  necessary  to  enumerate  the  various  morbid  conditions 
under  which  glycosuria,  in  whatever  degree,  has  been  met  with. 
It  may,  however,  be  stated  that  in  cases  where  there  is  a  dis- 
position for  sugar  to  appear  in  the  urine  without  any  special 
or  readily  recognized  cause,  there  is  much  risk  of  supervention 
ultimately  of  true  diabetes,  unless  the  morbid  tendency  be  early 
recognized  and  averted.  Thus  the  well-known  indigestion  of 
starchy  matter  leading  to  glycosuria  may  be,  for  a  time,  a  trivial 
matter  in  the  case  of  certain  obese  persons ;  but  if  a  restricted 
diet  in  respect  of  saccharine  and  amylaceous  food  be  not  taken, 
there  is  an  abiding  risk  of  true  diabetes  being  established,  which 
may  yield  to  no  plan  of  treatment. 

The  cases  which  I  seek  to  illustrate  in  this  connection  belong 
to  the  category  of  robust  and  corpulent  diabetic  patients.  They 
have  also  been  classified  in  the  Parisian  school,  especially  by  M. 
Lancereaux  and  M.  Lasegue,  as  the  fat  diabetics,  in  distinction 
to  the  lean.  Dickinson  describes  this  type  as  "  plump  and  rosy." 
In  a  considerable  proportion  of  this  class  it  is  found,  on  careful 
inquiry,  that  there  is  a  gouty  history  in  the  family  or  in  the 
patient,  and  in  some  cases  there  are  present  arthritic  changes, 
which  cannot  properly  be  called  gouty,  but  have  been  called 
rheumatic.  Of  the  latter  I  am  constrained  to  state  that  the  evi- 
dence forthcoming  is  but  small.      I  have  only  met  with  one  case, 


GLYCOSURIA.       SACCHARINE  DIABETES.  1 87 

which  I  shall  describe  later  on.  I  think  it  not  unlikely  that 
some  of  the  cases  in  which  glycosuria  has  been  found  have  really 
been  examples  of  gouty  disease,  inasmuch  as  the  diagnosis  is 
often  incorrect.  Charcot  remarks,  "  I  do  not  believe  that  diabetes 
has  ever  been  observed  as  a  complication  of  chronic  rheumatism," 
and  he  quotes  Griesinger's  statistics,  which  showed  only  two  cases 
of  acute  rheumatism  in  225  of  diabetes. 

Garrod,2  however,  has  described  a  well-marked  instance  in  a 
man,  get.  twenty-six,  who  suffered  from  typical  rheumatoid  arthri- 
tis, and  became  diabetic  five  months  after  the  disorder  began. 
He  also  had  cataract  in  one  eye,  and  died  within  nineteen  months 
of  pulmonary  phthisis. 

Dr.  Orel  relates  another  example.3 

It  is  important  next  to  examine  as  far  as  possible  in  what  pro- 
portion cases  of  diabetes  of  all  degrees  of  gravity  are  connected 
with,  or  related  to,  gouty  influence.  Charcot  quotes  statistics 
given  by  Griesinger  (who  studied  diabetes  amongst  all  classes 
of  patients),  which  yield  only  three  gouty  among  225;  also,  some 
by  Seegen,  who  practises  at  Carlsbad,  presumably  amongst  the 
wealthier  classes,  and  who  found  three  cases  in  thirty-one  dia- ' 
betics  (seven  in  140  cases,  as  quoted  by  Leeorche"  in  his  TraiU 
du  Diabete). 

It  is  of  interest  to  note  the  relative  frequency  of  the  occurrence 
of  this  variety  of  diabetes.  In  all  forms  of  the  disease  as  observed 
by  Griesinger,  gout  was  only  recognized  as  the  cause  in  .3  per 
cent. ;  in  Seegen's  cases,  gout  figured  in  9.3  per  cent,  ;  in  Schmitz' 
series,  in  7.5  per  cent.  ;  while  in  Dr.  Ord's  cases  of  mild  and  in- 
termittent diabetes,  36.3  per  cent,  were  thus  attributable. 

The  pathogenetic  relations  of  glycosuria  in  the  gouty  are  per- 
haps as  obscure  as  those  of  the  graver  forms  of  persistent  glyco- 
suria, which  are  truly  diabetic.  I  am  not  now  concerned  to  argue 
for,  or  against,  the   unity  of  all  glycosuric  or  diabetic  states.      I 

1  Op.  cit.,  note  to  p.  230. 

2  Op.  cit.,  p.  520,  case  given  at  length  with  necropsy.  Sir  Alfred  Garrod  informs 
me  that  he  has  met  with  other  cases  of  rheumatoid  arthritis  in  which  glycosuria 
occurred,  and  he  conceives  that  the  development  of  the  rheumatic  affection  may,  in 
some  cases,  be  aided  by  this  untoward  state. 

3  Loc.  cit. 

M.  LanceVeaux,  in  reply  to  my  request  for  his  experience  on  this  matter,  writes 
as  follows  :— "  Assez  rarement  j'ai  rencontre"  le  diabete  dans  le  rhumatisme  noueux  ; 
e'etait  encore  le  diabete  gras.  Existait-il  une  relation  entre  les  deux  &ats  patho- 
logiques?  Je  ne  le  pense  pas.  J'ajouterai  qu'il  est  parfois  facile  de  confondre  le 
rhumatisme  avecla  goutte." 

Dr.  Wynne  Foot,  whose  experience  of  rheumatoid  arthritis  in  Dublin  is  very  large, 
states  that  he  has  not  observed  glycosuria  in  connection  with  it. 


1 88      RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 

have  already  mentioned,  what  is  unfortunately  a  clinical  fact,  that 
the  milder  form  of  gouty  glycosuria  may  sometimes  eventuate  in 
chronic  diabetes. 

The  view  of  the  matter  which  best  commends  itself  to  my 
mind  is,  that  glycosuria  occurring  in  those  of  gouty  heritage,  or 
already  gouty  in  some  fashion,  is  to  be  regarded  as  a  form  of  vis- 
ceral gout,  the  organ  mainly  in  fault  here  being  the  liver.  As 
with  gouty  processes  generally,  so  here,  a  neuro-humoral  patho- 
logy is  necessary  for  a  due  conception  of  the  disorder.  On  the 
nervous  side,  regard  must  be  had  to  the  causes  commonly  prevail- 
ing in  these  cases,  which  are  such  as  to  entail  strain  and  exhaus- 
tion of  the  great  centres,  thus  predisposing  to  instability  and  a 
neurotic  state.  The  lines  of  morbid  action  here  are  conceivably 
somewhat  as  follows  : — As  a  result  of  irritation  or  exhaustion- — pos- 
sibly some  definite  (as  yet  undetected)  lesion  of  the  cerebro-spinal  or 
sympathetic  nervous  system — a  vaso-motor  change  occurs  either 
in  the  direction  of  irritation  or  paralysis.  The  morbid  impulses 
take  the  route  of  the  cervical  portion  of  the  chord,  pass  through 
the  inferior  cervical  sympathetic  ganglion,  and  so,  by  the  splanch- 
nic branches,  reach  the  coeliac  plexus.  The  result  is  either  a 
temporary  irritation  or  a  more  permanent  passive  dilatation  of  the 
hepatic  arterial  system,  a  prime  factor  in  glycosuria.  Such  is  a 
hypothetical  mechanism  for  the  impulses  of  central  origin.  It  is, 
however,  conceivable  that  similar  morbid  impulses  may  proceed 
directly  from  the  coeliac  plexus,  instigated  by  irritation  arising 
in  the  digestive  tract  from  forms  of  dyspepsia,  perhaps  espe- 
cially from  such  as  lead  up  to  a  gouty  state.  Uric  acid,  when 
retained  in  the  system,  is  believed  to  be  stored  in  the  liver  and 
spleen,  and  its  presence  in  excess  in  the  former  organ  may,  as  has 
been  conceived  by  Ord,  excite,  under  some  conditions,  a  veritable 
gout  of  the  liver.  The  prevailing  vascular  condition  of  the  organ 
will,  thus,  be  one  of  high  tension  with  hyperemia,  one  eminently 
favourable  to  glycogenesis.  On  the  humoral  side,  the  peccant 
matter  is  probably  uric  acid  acting  as  a  local  visceral  irritant.1 

1  The  late  Dr.  Milner  Fothergill  remarked  that  "  glycosuria  is  common  in  stout 
persons,  whose  digestion  of  starch  is  perfect,  and  in  whom  the  liver  only  dehydrates 
enough  into  glycogen  for  the  wants  of  the  system,  the  surplusage  running  off  by  the 
kidney.  If  it  were  not  for  this  'waste-pipe,'  the  individuals  would  become  inordi- 
nately fat.  Such  glycosuria  is  quite  different  from  diabetes  leading  to  wasting, 
where  either  (i.)  the  liver  has  lost  the  power  of  dehydrating  the  sugar  brought  to  it 
by  the  portal  vein — the  more  probable  hypothesis — or  (2.)  the  ferments  in  the  liver 
hydrate  the  glycogen  or  animal  starch  into  sugar  again  too  swiftly  for  the  wants  of 
the  body,  and  the  '  fuel  food '  escapes  unburnt.  If  food,  which  undergoes  no  saccharine 
transformation,  can  be  taken  in  sufficient  quantity  and  assimilated,  the  diabetic  is 
preserved;  if  not,  he  perishes." — Indigestion  and  Biliousness,  &c,  p.  94,  18S1. 


GLYCOSURIA.       SACCHARINE    DTABETES.  1S9 

Dr.  Haig  has  shown  that  dyspeptic  conditions  in  the  gouty- 
may  be  induced  by  hepatic  congestion,  and  lead  to  a  fall  in  the 
acidity  of  the  blood  with  a  corresponding  excretion  of  uric  acid. 
Thus  may  be  explained  the  temporary  glycosuria  of  the  gouty, 
which  not  infrequently  alternates  with  discharge  of  free  uric  acid 
in  the  urine.  By  repeated  attacks  of  this  peculiar  metabolic 
disturbance  in  the  liver,  and  possibly  with  slighter  provocation, 
the  vicious  habit  tends  to  become  permanent,  and  we  have  to  deal 
with  a  hepatic  form  of  diabetes,  due  to  vaso-motor  paralysis,  pro- 
bably often  in  association  with  another  form  due  to  gastrointes- 
tinal dyspepsia  with  over-production  of  glucose. 

In  confirmed  cases  of  glycosuria  in  the  gouty,  there  is  not 
improbably  established  a  central  neurosis,  which  persistently  domi- 
nates the  whole  course  of  the  malady. 

We  are  thus  in  the  presence  of  a  well-marked  form  of  visceral 
gout,  and  the  evidence  of  its  gouty  dependence  is  seldom  far  to 
seek  in  these  cases.  The  family  history  and  the  personal  pro- 
clivities of  the  patient  strongly  attest  a  gouty  habit,  and  I  feel  as 
convinced  of  the  fact  that  glycosuria  is  here  the  indication  of  the 
disturbance  wrought  locally  in  the  liver  by  gouty  influence,  as  I 
am  of  the  corresponding  mischief  which  is  sometimes  effected  in 
the  kidneys  when  the  gouty  process  is  established  in  those  organs, 
leading  to  cirrhosis,  with  polyuria  and  occasional  albuminuria. 
In  neither  case  may  any  marked  or  classical  articular  troubles 
occur,  but  in  each  it  is  not  uncommon  to  meet  with  articular  gout. 

The  most  obvious  fact  to  be  noted  in  most  of  the  cases  now 
under  consideration  is  that  the  patients  do  not  present  the  ordi- 
nary aspect  or  recognized  symptoms  of  diabetes  as  commonly 
understood.  There  is  often  no  diabetes  whatever  in  the  etymo- 
logical sense,  and  the  first  indications  are  manifested  either  to  the 
physician  in  the  test-tube,  or  to  the  patient  by  the  symptoms  of 
some  undue  thirst,  slight  muscular  weakness,  loss  of  flesh,  and 
more  frequent  micturition,  and  in  women  not  unfrequently  by 
troublesome  vulvar  itching.  Such  patients  are  commonly  robust 
in  appearance,  in  middle  life,  of  large  frame,  and  frequently  corpu- 
lent, with  much  abdominal  obesity. 

The  latter  condition  has  been  often  observed  to  precede  the 
occurrence  of  glycosuria,  and  in  the  course  of  the  disorder  a  large 
reduction  in  its  bulk  may  take  place. 

It  is  certain  that  the  degree  of  glycosuria  may  vary  largely  in 
different  cases  and  in  the  same  individual  at  different  periods, 
also,  that  the  tolerance  of  the  system  for  saccharine  impregnation 
varies  much  in  individuals. 


190      RELATION    OF    GOUT    TO    OTHER    MORBID    STATES. 

In  all  diabetic  persons,  regard  must  be  had  not  only  to  the 
amount  of  glucose  produced  and  discharged,  but  also  to  the  double 
effect  of  the  impregnation  itself  on  the  various  tissues,  and  the 
degree  of  general  cachexia  which  gradually  ensues  as  the  result 
of  the  malady.  Hence,  it  is  otten  more  important,  if  it  be  pos- 
sible, to  treat  the  cachexia  than  the  leading  symptom,  and  it  is 
always  necessary  for  the  real  welfare  of  the  patient  to  treat  him 
rather  than  his  ailment.  This  is  a  point  requiring  special  atten- 
tion in  the  later  stages,  and  it  is  sometimes  quite  overlooked. 

Little  is  known  as  to  the  direct  influence  of  an  abiding' 
saccharine  impregnation  upon  the  various  textures  of  the  body. 
It  can  hardly  be  supposed  to  be  innocent,  yet  in  many  cases  it 
appears  to  be  so.  It  is  certain  that  vascular  degeneration  is  not 
common  in  diabetes  of  the  gravest  character,  and  where  it  is  met 
with,  it  occurs  in  cases  the  nature  of  which  is  now  under  discussion, 
where  the  arthritic  element  prevails  and  leads  to  this  particular 
change  (arthritic  cachexia — Laycoclz). 

Wasting  extends  to  fat  and  muscle,  and  the  skin  may  wrinkle 
in  consequence,  although  perspiratory  function  is  not  checked. 
Some  enfeeblement,  with  intermission,  of  the  heart's  action  has 
been  observed  in  the  depressed  state  of  health  met  with  after  the 
glycosuria  has  run  on  for  some  time  untreated. 

This  cardiac  failure  is  sometimes  very  marked  in  advanced 
cases.  I  have  notes  of  one  instance  where  the  greatest  relief  was 
always  obtained  when  a  quantity  of  sugar  was  added  to  the  diet, 
the  patient  feeling,  as  he  stated,  "  pulled  together  "  by  it. 

Amongst  the  mental  conditions,  undue  irritability  of  temper  is 
to  be  noted.  This  is  well-recognized  amongst  gouty  patients  ; 
but  this  altered  state  is  sometimes  met  with  in  ordinary  diabetic 
patients,  and  cannot  be  considered  peculiar  to  this  form  of  the 
malady. 

Severe  intercostal  neuralgia  has  been  found  associated  with  this 
diathetic  diabetes.  I  shall  subsequently  append  a  short  note  of 
one  case,  and  Sir  William  Roberts  has  reported  another  which 
presented  many  features  in  common  with  it.1  Both  occurred  in 
elderly  persons.  Sometimes  dyspnoea  suddenly  supervenes  in  obese 
glycosuric  patients  with  precordial  distress  and  palpitation,  con- 
stituting a  pseudo-anginal  attack.  There  may  be  dilatation  of 
the  cardiac  walls  in  advanced  cases  after  the  obesity  has  begun  to 
pass  off. 

Arterial  sclerosis  may  gradually  set  in,  and  make  progress  in 
long-standing  cases. 

1  Op-  cit,,  p.  262. 


GLYCOSURIA.      SACCHARINE  DIABETES.  191 

Examples  of  gouty  diabetes,   if  they  may  so   be  termed,  are 
found  to  occur   more   frequently  in  the   male   sex.       This    is    in 
accordance  with  the  greater  prevalence  of  gout  in  that  sex.      The 
majority  of  patients  thus  affected  have  either  been  the  subject  of 
gouty  attacks  at  some  period,  or  a  clear  history  of  gout  in  their 
families  is  elicited.     They  sometimes  prove  to  have  been  large 
eaters  and  free-livers,  and  to  have  much  appetite  for  bread,  pota- 
toes, and  sweets.      In  many  of  the  cases  a  noteworthy  history  of 
mental  anxiety,  shock,  worry,  or  of  chagrin  appears  to  have  been 
the  precise  determining  factor,  and  from  the  date  of  such  trouble 
the  diabetic  symptoms  are  found  to  have  arisen.      Recrudescence 
may  be  excited  by  mental  shock  and  anxiety.     In  other  instances, 
exposure   to   cold   and  damp  appears  to  have  been  an  exciting 
cause,  and  recrudescence   of  the  disorder  has  also  been  traced  to 
the  too  bracing  influences  of  east  winds,  especially  at  the  seaside, 
and  in  connection  with  sea-bathing  in  unsuitable  weather.      It 
has  been  asserted1  that  sea-air  is  generally  injurious  to  diabetic 
patients,   and  facts  are  not  wanting  in  proof  of  the  statement. 
Bilious  symptoms  and  pneumonia  have  been  found  prominent,  and 
patients   have  begun  to  fall  back  from  the  time  seaside  residence 
ensued.     The  late  Dr.  Camplin  insisted  strongly  upon  the  inadvisa- 
bility  of  making  any  important  change  in  the  diet  or  habits  of  a 
diabetic  person  during  the  prevalence  of  east  and  north-east  winds. 
The  amount  of  glucose  in  the  urine  may  vary  much,  as  has 
been  already  stated.      Sometimes   the   urina  sanguinis   is   more 
charged  than  the  urina  cibi  in  the  same  case.      This  is  commonly 
regarded  as  a  grave  sign  in  any  instance  of  diabetes,  as  indicating 
a  more  confirmed  vicious  habit.      The   whole   amount   of  urine 
passed  may  not  exceed  the  normal  quantity  of  health,  or  may  even 
sometimes  be  below  this. 

In  respect  of  the  albuminuria  accompanying  the  cachectic  con- 
dition, with  cardio- vascular  changes,  sometimes  reached  in  those 
cases,  Schmitz  found  that  the  glucose  and  albumen  were  often 
passed  in  inverse  ratio.  After  exhaustion  and  severe  efforts  the 
albumen  was  increased ;  there  was  more  in  the  night-  than  in  the 
day-urine,  and  after  food  the  amount  of  it  diminished.  The  spe- 
cific gravity  may  be  of  high  range.  I  have  a  record  of  one  case 
where  it  was  1.060  and  over  for  some  years. 

With  the  removal  of  the  sugar  under  dietetic  treatment  and 
other  invigorating  influences,  uratic  and  free  uric  acid  sediments 
may  occur  in  the  urine,  gouty  pains  return  in  various  joints,  and 
itching  eczematous  eruptions  appear  on  the  limbs. 

1  Frederick  Simms.     Brit.  Med.  Journ.,  December  1SS1,  p.  1006. 


192   KELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

I  suspect  that  it  is  in  cases  of  this  nature  that  anthrax  and 
furuncular  inflammation  are  especially  apt  to  occur.  It  is  not 
within  my  experience  that  grave  aud  intractable  cases  of  diabetes 
often  present  this  symptom.  Marchal  called  these  boils  "  furoncles 
uriques,"  and  regarded  them  as  "  gout  of  the  cellular  tissue," 
believing  that  they  were  vicarious  of  more  obvious  gouty  inflam- 
mation in  the  joints,  and  that  in  the  subjects  of  them  the  urine 
contained  excess  of  uric  acid. 

It  is,  of  course,  possible  that  a  single  examination  of  the  urine 
in  some  of  these  cases  may  reveal  no  glycosuria ;  there  may  be 
excess  of  uric  acid,  and  the  glucose  may  reappear  subsequently. 
Regard  must  be  had  to  the  life-history  and  other  characteristics 
of  the  patient  in  making  the  diagnosis.  Anthrax  is  found  to  be 
more  frequent  in  the  male  sex.  Some  indication  of  its  occasional 
connection  with  a  gouty  habit  may  be  gathered  from  the  fact, 
now  admitted  by  most  surgeons,  that  it  is  best  treated  without 
stimulants,  or  with  only  a  moderate  amount  of  them,  and  by 
milk-diet. 

In  these  cases  it  is  certainly  not  usual  to  meet  with  the  dis- 
order which  affects  the  teeth  and  gums  in  the  graver  forms  of 
diabetes. 

If  the  disease  be  unrecognized  and  untreated,  and  drift  into 
an  incurable  state,  so  that  the  diabetic  cachexia  is  induced,  the 
conditions  of  alveolar  catarrh,  osteo-periostitis,  and  loosening 
supervene,  all  which  have  been  well-described  by  M.  Magitot 
of  Paris.1 

The  same  may  be  stated  respecting  the  troubles  of  vision, 
such  as  asthenopia  and  cataract,  which  belong  to  the  diabetic 
cachexia,  and  are,  therefore,  only  met  with  in  confirmed  cases, 
which  hardly  yield  to  treatment. 

The  "  sweet  breath "  of  the  severe  form  of  diabetes  is  not 
usually  observable  in  these  milder  cases.  Dryness  of  the  mouth 
may,  however,  occur,  as  well  as  thirst  during  acute  exacerbations 
of  the  disorder. 

The  skin  retains  its  softness,  and  perspiration  is  not  reduced 
in  amount.  I  have  seldom  met  with  any  tophi  in  these  cases  ;  but 
in  one  instance  there  was  a  small  crab's-eye  cyst  over  a  terminal 
phalangeal  tubercle. 

Gangrene  of  the  extremities  has  been  known  to  occur  in  cases 

of  this  form  of  diabetes.      It  is  not  by  any  means  peculiar  to 

them.      The  prognosis  is  not  necessarily  bad,  and,  with  care,  this 

alarming  condition  may  issue  favourably.      The  textures  appear 

1  Paper  read  before  the  Academy  of  Medicine.     Paris,  188 1. 


GLYCOSURIA.         SACCHARINE   DIAEETL<.  1 93 

to  become  unduly  vulnerable  in  all  cases  of  long-continued  dia- 
betes, when  the  patient  may  be  considered  cachectic. 

According  to  Marchal,  cerebral  apoplexy  is  common  in  the 
gouty  and  in  the  gouty  diabetic. 

The  subjects  of  gouty  glycosuria  are  usually  mentally  vigorous 
and  active,  "  men  of  affairs/'  acting  under  pressure  and  respon- 
sibility. They  often  have  large  appetites,  and  so  combine,  not 
seldom,  both  high-living  and  high-thinking.  The  trouble  is  apt 
to  come  on  in  the  fourth  or  fifth  decade. 

I  have  already  alluded  to  the  fugitive  glycosuria  met  with  in 
acute  gout.  This  may  be  regarded  as  the  simplest  form  of  it, 
and  it  passes  off,  not  to  recur,  in  the  majority  of  cases. 

In  other  instances  there  may  be  temporary  glycosuria  of  more 
importance,  and  it  may  alternate  with  actual  gouty  joint-troubles. 
or  with  active  phases  of  goutiness  elsewhere,  the  srlucose  dis- 
appearing, and  uric  acid  sometimes  appearing  in  place  of  it  in  the 
urine. 

The  urine  in  these  cases  is  usually  very  bright,  acid,  and 
refracting,  the  only  deposit,  when  it  occurs,  being  uric  acid  in 
crystals  ;  and  hence  it  is  very  different  from  the  loaded  urines, 
which  become  turbid  and  throw  down  uratic  salts.  As  Pavy  has 
shown,  when  these  cases  are  successfully  brought  under  control,  a 
copious  deposit  of  urates  occurs,  and  this  is  one  of  the  best  sisms 
that  can  be  witnessed.  The  natural  acidity  of  the  urine  may  be 
increased  through  the  occurrence  of  lactic  acid  fermentation,  and 
thus  uric  acid  falls  just  as  if  an  acid  had  been  added  to  healthy 
urine. 

Each  case  presenting  symptoms  of  gouty  glycosuria  must  be 
a  special  study  to  the  physician.  No  two  are  alike  in  degree,  or 
subject  to  uniform  prognosis.  The  disorder  may  endure  for  many 
years,  even  when  permanently  established.  ALuch  will  depend 
on  the  original  vigour  of  the  constitution,  the  strength  of  will  to 
submit  to  adjusted  (not  necessarily  restricted)  dietary,  and  the 
available  means  to  maintain  the  highest  standard  of  bodily  and 
mental  health.  I  know  of  nothing  more  harmful  for  such  patients 
than  to  pronounce  them  the  subjects  of  diabetes,  the  idea  of  which 
commonly  conveys  very  depressing  and  mischievous  impressions, 
difficult  to  remove.  If  such  cases  be  treated  as  those  of  the  srraver 
form  of  diabetes  should  be.  they  become  worse,  losing  flesh  and 
nervous  tone. 

The  disorder  may  appear  in  young  women,  descendants  from  a 
gouty  ancestry,  and  the  approaches  of  it  are  sometimes  insidious. 
Slight  failure  of  power,  with  seeming  health,  ruddiness,  and  even 


194      DELATION    OF    GOUT   TO    OTHER    MORBID    STATES. 

buxonmess,  should  lead  to  examination  of  the  urine  for  glucose, 
which  may  be  present  at  first  fngitively,  or  in  small  amount 
persistently.  For  purposes  of  proper  treatment,  it  is  well  to  be 
early  aware  of  the  tendency.  If  the  urine  is  not  copious,  it  is  apt 
to  be  concentrated ;  hence,  there  is  incomplete  washing  out  of  the 
tissues,  and  tendency  for  urates  to  remain  in  the  system. 

I  have  noted  the  occurrence  of  strange  and  indescribable  sen- 
sations down  the  spine  and  in  the  limbs  in  patients  thus  affected. 
Fatigue  and  sudden  emotion  are  apt  to  induce  this. 

They  sometimes  suffer  from  paroxysms  of  intense  burning  sen- 
sation in  the  hands  and  feet,  a  true  causalgia,  and  have  a  constant 
air-hunger,  being  intolerant  of  hot  rooms  and  aggregations  of 
people.      Hepatic  pain  is  sometimes  experienced. 

The  appetite  is  apt  to  be  capricious,  and  there  may  be  periods 
when  there  is  actual  loathing  of  all  kinds  of  food. 

The  glucose  may  largely  disappear  and  give  way  to  uric  acid 
or  uratic  sediments,  the  quantity  of  urine  diminishing  at  the  same 
time.  With  this  phase  there  is  general  discomfort  of  the  system, 
and  aggravation  of  the  various  gouty  symptoms  common  in  these 
patients.  Alternations  of  glycosuria  with  attacks  of  gout  or  uri- 
nary gravel  may  occur  (diabetes  alternans). 

Diarrhoea  may  be  almost  a  constant  condition,  and  the  super- 
vention of  constipation  in  such  cases  adds  much  to  the  malaise. 

I  have  known  copious  sweating  occur  for  long  periods,  but  it 
has  afforded  no  manner  of  relief  to  other  symptoms,  as  might 
have  been  anticipated,  rather  the  contrary.  Shingles  may  some- 
times be  met  with. 

It  has  been  already  observed  that  with  the  onset  of  glycosuria 
or  gouty  diabetes  (with  polyuria)  the  tendency  to  paroxysmal  joint- 
attacks  ceases.  I  can  confirm  this  experience  as  applying  to  the 
greater  number  of  cases  met  with,  so  that  the  more  diabetes  there 
is  present,  the  less  gout  there  is.  Minor  and  incomplete  attacks, 
articular  and  abarticular,  may,  however,  arise  in  these  subjects, 
especially  if  there  is  no  polyuria. 

In  Chapter  x.  p.  224,  I  have  referred  to  a  remarkable  case  in 
which  acute  arthritic  gout  occurred  in  the  course  of  well-estab- 
lished glycosuria. 

I  have  met  with  several  cases  in  which  deep-seated  and  severe 
dorsal  and  lumbar  pains  have  been  associated  with  this  state, 
suggesting  the  onset  of  aortic  aneurysm  or  of  a  new  growth  press- 
ing on  the  spinal  nerves,  neither  of  which  occurred ;  in  these 
cases  relief  was  only  procurable  by  dosage  with  anodynes  repeated 
over  long  periods.      These  pains  were  probably  due  to  neuralgia. 


GOUT    AND    OBESITY.  1 95 

The  occurrence  of  glucose  in  the  urine  of  patients  suffering 
from  rheumatic  fever,  and  treated  for  this  with  sodium  salicylate, 
is  possibly  of  interest  in  relation  to  gouty  glycosuria.  Salicylate- 
glycosuria  occurs  when  the  toxic  symptoms  of  the  drug  (such 
as  tinnitus  aurium  and  deafness)  are  manifested  by  the  nervous 
system. 

As  in  all  varieties  of  diabetes,  so  in  this,  prognosis  is  largely 
influenced  by  the  age  of  the  patient.  Every  decade  beyond  forty 
is  in  favour  of  any  given  case,  and  considerable  anxiety  must 
attach  to  most  instances  below  that  age. 

Glycosuria  in  connection  with  gout  is  not  likely  to  be  met 
with  before  the  third  decade,  nor  before  such  time  as  ordinary 
manifestations  of  gout  occur.  Diabetes  in  all  varieties  is  most 
common  between  thirty  and  sixty  years  of  age.  Cases  of  ordinary 
diabetes,  not  necessarily  presenting  any  arthritic  features,  are 
met  with  in  the  descendants  of  the  gouty  at  an  earlier  period. 
Amongst  my  cases  I  find  those  of  a  young  lady  of  eighteen  and 
a  man  aged  twenty-one.  Such  a  history  is  not  uncommon  in 
gouty  families,  and  is  fully  recognized  in  France. 

7.— Relationship  between  Gout  and  Obesity. 

Amongst  evolutionary  developments  of  the  gouty  habit  is 
obesity  in  some  members  of  families  thus  affected.  This  was 
recognized  by  Bouchard,  Charcot,  and  others  in  France,  and  by 
Laycock,  of  Edinburgh.  The  latter,  in  his  nosology,  remarked 
that  fatty  constitutional  diseases  were  allied  to  gouty  diseases. 
In  ninety-four  cases  of  obesity  collected  by  Bouchard,  there 
were  gouty  antecedents  in  twenty-eight,  and  rheumatic  in  thirty- 
three.  Allied  gouty  states  also  prevailed  in  a  majority  of  the 
remainder,  such  as  migraine,  diabetes,  lithiasis  (renal  and  biliary), 
eczema,' and  neuralgia.  This  is  very  strong  evidence  in  support 
of  an  arthritic  habit  in  association  with  obese  tendency  in  the 
offspring.  There  is  sometimes  coincidence  of  obesity  and  actual 
gout. 

Cases  of  marked  obesity,  sometimes  even  developing  before 
puberty,  are  found  to  occur  in  the  families  of  the  gouty.  A 
single  member  in  such  a  family  may  alone  show  this  tendency, 
of  which  I  have  known  several  instances. 

The  occasional  association  of  renal  calculi  with  obesity  has  long 
been  noted. 

In  proof  of  the  affinity  of  obesity  to  the  gouty  habit  may  be 
cited  the  figures  of  Bouchard,  who  found  in  a  hundred  cases  of 


196   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

biliary  lithiasis  seventy-two  examples  of  obesity  amongst  the 
personal  and  hereditary  antecedents,  and  thirty-five  cases  amongst 
the  direct  parentage.  Amongst  the  parentage  were  also  thirty 
cases  of  gout. 

Obesity  is  met  with  in  association  with  glycosuria  in  the  gouty, 
the  variety  of  "  fat  diabetes "  numbering  many  in  this  class. 
Sometimes  cases  of  extreme  polysarcia  occur  with  this  associa- 
tion. The  obesity  may  long  precede  the  onset  of  glycosuria,  and 
in  such  instances  glucose  should  be  occasionally  sought  for  in 
the  urine,  and,  if  found,  be  met  by  appropriate  (not  too  rigid) 
treatment.  Such  diabetic  patients  may  lose  their  fat  gradually, 
and  become  "  lean  diabetics  ;  "  but  this  does  not  always  happen. 
They  are  met  with  in  both  sexes. 

There  is  some  tendency  in  the  gouty  to  formation  of  fatty 
tumours,  which  may  occur  singly  or  in  multiform  variety.  These 
are  best  left  alone,  certainly  after  middle  life,  and  treated, 
according  to  the  dictum  of  a  distinguished  Irish  surgeon,  "  with 
contempt." 

8.— Relationship  between  Gout  and  Oxaluria. 

The  frequent  occurrence  of  calcium  oxalate  in  the  urine  under 
varied  conditions  in  persons  with  and  without  symptoms  indicat- 
ing its  presence  is  well-recognized.1  Garrod,  I  believe,  was  the 
first  to  demonstrate  that  the  blood  in  gout  contains  oxalic  acid.2 
He  relates  that  he  has  frequently  found  it,  and  believes  that  it 
chiefly  occurs  during  the  inflammatory  stage,  and  is  probably 
derived  from  uric  acid  by  oxydation.  He  detected  it  also  in  the 
sweat  of  two  gouty  patients. 

Prout  remarked  that  the  oxalic  acid  diathesis  differed  from  dia- 
betes in  its  non-liability  to  be  excited  by  an  attack  of  gout,3  but 
that  oxalic  acid  calculus  occasionally  followed  such  an  attack.  He 
noted  that  oxalic  acid  concretions  sometimes  replaced  those  of 
uric  acid  in  the  same  case,  and  that  persons  of  the  oxalic  acid 
diathesis  subsequently  became  glycosuric.  He  found,  further,  that 
the  subjects  of  oxalic  acid  diathesis  sometimes  began  to  secrete  an 
excess  of  carbonate  of  lime,  and  as  the  quantity  of  lime  increased, 
that  of  oxalic  acid  diminished,  while  the  phosphoric  acid  increased 

1  "  On  Dyspepsia  and  Nervous  Disorders  in  connection  with  the  Oxalic  Diathesis." 
Contrib.  to  Pract.  Med.,  by  James  Begbie,  Edin.,  p.  178,  1862. 

Vide   "Notes    on   Oxaluria."     St.   Barth.    Hosp.   Reports,   vol.  ii.  p.   160,    1866. 
(Paper  by  myself.) 

2  Med.  Chir.  Trans.,  vol.  xxxii.,  1849. 

3  On  Stomach  and  Renal  Diseases,  p.  70,  1843. 


GOUT    AND    OXALURIA.  I  97 

until  nearly  pure  phosphate  of  lime  was  excreted.  During  the 
transition  the  urine  frequently  deposited  triple  phosphate,  but  less 
of  this  occurred  than  when  uric  acid  deposits  were  transformed 
into  phosphatic  deposits.  In  children,  the  transition  from  oxalates 
to  phosphates  was  found  to  be  often  accompanied  by  white  urates, 
as  well  as  by  triple  phosphate  of  magnesium  and  ammonium. 
Most  practical  physicians  probably  agree  that  in  these  several 
transitions  there  is  nothing  to  be  noted  in  the  patients  which  in 
any  way  suggests  a  gouty  habit  of  body. 

The  significance  of  oxalate  of  lime  deposits  is  certainly  varied, 
and  may  be  stated  as  dependent  mainly  on  the  following  condi- 
tions : — (a.)  Direct  ingestion  of  oxalic  acid  in  certain  articles  of  food, 
as  rhubarb,  sorrel,  tomatoes,  celery,  watercress,  &c. ;  (Jj.)  imperfect 
oxydation  of  saccharine,  starchy,  and  oleaginous  principles  of  food  ; 
(c.)  increased  tissue-metabolism,  whereby  the  fatty  acids  found  in 
excess  are  incompletely  reduced ;  (d.)  excess  of  lactic  and  butyric 
acids,  formed  in  intestinal  dyspepsia,  insufficiently  reduced  ;  (e .) 
excess  of  mucus  in  urinary  channels,  which  tends  to  ferment  and 
favour  deposition  of  oxalates  ;  and  (/.)  ingestion  of  water  rich  in 
lime-salts. 

Prout  considered  that  the  fact  of  oxalates  appearing  in  the  urine 
after  partaking  of  food  containing  oxalic  acid  indicated  feebleness 
of  digestion,  inasmuch  as  a  healthy  stomach  should  convert  small 
quantities  of  this  acid  into  more  disposable  matters,  as  carbonic 
acid.  In  graver  cases,  when  the  mal-assimilation  resulted  from 
imperfect  transformation  of  ordinary  food,  there  is  usually  pre- 
sent a  form  of  catarrhal  dyspepsia  affecting  the  whole  alimentary 
canal.  The  liver  is  disordered  in  such  cases,  the  biliary  dis- 
charges being  varied  in  colour,  the  motions  acid,  and  covered  with 
mucus. 

I  have  certainly  met  with  discharges  of  oxalate  of  lime  in 
persons  of  gouty  habit,  and  suspect  that  the  tendency  to  the 
forms  of  dyspepsia  and  mal-assimilation  which  lead  to  oxaluria  is 
closely  allied,  if  not  quite  akin,  to  that  prevailing  in  the  gouty. 
The  articles  of  food  which  are  bad  for  those  with  tendency  to 
oxaluria  are  just  those  which  are  ill-borne  by  the  gouty,  and  the 
dietetic  conditions  for  the  one  are  proper  for  the  other.  Urates 
and  oxalates  often  co-exist  in  the  urine  of  the  gouty  dyspeptic. 

It  was  formerly  believed  that  oxalates  were  derived  from  the 
subsequent  decomposition  of  the  uric  acid  in  the  urine  passed. 
It  is  now  known  that  oxalic  acid  results  from  free  oxydation  of 
uric  acid,  and  that  this  active  oxydation  can  proceed  in  the 
system  in  disorders  attended  by  free  metabolism  and  oxydation. 


198      RELATION"    OF    GOUT    TO    OTHER   MORBID    STATES. 

The  amount  of  oxalates  passed  in  some  cases  is,  however,  much 
larger  than  can  possibly  be  accounted  for  by  the  amount  of  uric 
acid  either  in  the  body  or  in  the  urine,  and  hence  must  commonly 
own  other  sources,  as  has  just  been  indicated. 

A  tendency  to  boils  and  carbuncles  has  been  noted  in  the 
subjects  of  persistent  oxaluria,  and  the  same  is  found  sometimes 
in  those  suffering  from  glycosuria. 

The  relation  of  oxaluria  to  gout  may,  therefore,  be  defined  as 
indirect,  and  dependent  on  the  degree  of  primary  and  secondary 
faults  in  the  digestive  processes.  No  directly  gouty  symptoms 
are  referable  to  excess  of  oxalic  acid,  but  its  presence  in  undue 
amount  may  be  associated  with  forms  of  dyspepsia  and  with 
mental  depression,  to  which  the  gouty  are  obnoxious,  and  on 
which  many  of  the  manifestations  of  gout  depend.  Oxaluria  may 
thus  be  a  harbinger  of  more  overt  gouty  symptoms,  and,  as 
such,  may  help  as  a  guide  in  the  treatment,  by  way  of  preven- 
tion, of  future  gouty  troubles. 

With  respect  to  calculi  of  calcium  oxalate,  it  may  be  stated, 
generally,  that  they  are  far  less  common  than  those  of  uric  acid, 
and  that  the  calculi  met  with  in  the  gouty  usually  consist  of  the 
latter.  Sometimes,  the  concretions  consist  of  alternate  layers  of 
each. 

9.— Relation  between  Gout  and  Splenic  Leuchsemia. 

In  some  cases  of  splenic  enlargement  uric  acid  has  been 
observed  to  pass  freely  out  of  the  body  by  way  of  the  kidneys.1 
The  spleen  is  now  regarded  by  physiologists  as  a  temporary  store- 
house for  uric  acid  in  cases  of  retention  of  this  matter.  The 
liver  is  also  believed  to  retain  much  uric  acid  when  there  is 
defective  excretion  of  it.  Cases  of  splenic  leuchgemia  might, 
therefore,  be  expected  to  furnish  examples  of  gout ;  but  such 
an  association  has  not  been  hitherto  found  with  any  frequency. 
Ebstein  affirms  that  gout  and  leucheemia  never  occur  together. 

The  following  cases  are  the  only  ones  known  to  me  : — 

(1.)  An  adult  male  had  become  pallid,  and  felt  weak  for  eighteen  months  or  two 
years.  The  spleen  and  liver  were  much  enlarged.  The  leucocytes  numbered  one  to 
five  red  blood-globules.  No  history  of  ague.  The  urine  contained  a  trace  of  albu- 
men and  urates,  but  no  uric  acid  crystals  were  thrown  down  in  it.  No  family  history 
of  gout,  and  no  lead-impregnation.  After  a  time  an  acute  attack  of  gout  supervened 
in  the  left  great-toe  at  night.  Under  colchicum  the  arthritis  passed  off  in  a  few 
days.     A  year  previously  a  similar  attack  of  gout  occurred  in  the  same  toe. 

1  In  some  cases  of  splenic  leuchaemia,  the  amount  of  uric  acid  excreted  has  been 
found  to  vary  from  twice  to  seven  times  the  normal  amount.  Renal  calculi  of  uric 
acid  are  sometimes  formed  and  passed. 


PURPURA.  I99 

The  following  case  came  under  my  care  in  1880  : — 

(2.)  W.  F.,  set.  fifty-six,  a  printer,  had  gout  in  right  great-toe  fourteen  years  ago,  a 
year  afterwards  in  right  elbow,  and  since  in  elbows,  wrists,  shoulders,  neck,  and 
right  hip-joint.  More  attacks  on  left  than  on  right  side  of  body.  No  lead-taint 
recognizable.  Arteries  thickened.  Tophi  on  knuckles  and  both  ears.  Skin  smooth, 
eyelids  puffy.  Acute  attacks  always  begin  in  the  daytime.  Present  attack  in  right 
wrist  and  hand.  Is  the  eldest  son.  Maternal  grandfather  had  gout.  Parents  free. 
Has  taken  "all  the  pills  famous  for  gout."  Urine,  trace  of  albumen,  several  noc- 
turnal micturitions.  Treated  with  iodide  and  bromide  of  potassium,  and  solution  of 
veratrina  (gr.  x.  ad  f.  qu),  painted  over  painful  parts.  Relieved  in  two  days  (sixth  of 
paroxysm).  Skin  desquamating  on  ninth  day  over  late  seat  of  pain.  In  two  weeks 
great  improvement.  Bark  and  mix  vomica  given  with  iodide  of  potassium,  after- 
wards iodide  of  iron.  This  patient  was  in  the  hospital  eighteen  months  previously 
with  enlarged  glands  on  both  sides  of  the  neck,  and  had  an  attack  of  gout.  The 
enlargement  subsided  for  twelve  months,  and  then  returned.  Six  months  ago  the 
glands  were  enlarged  in  the  groins.  Three  weeks  ago  those  in  the  neck  and  axillae 
swelled,  and  the  spleen  was  found  much  enlarged,  measuring  d\  inches  long,  by 
the  same  in  breadth.  Increase  of  leucocytes  found  in  blood  under  microscope.  Six 
months  later  the  spleen  measured  nine  inches  vertically.  Recent  attack  of  gout  in 
both  knees  with  much  effusion.  Three  months  subsequently,  renewed  attacks  of 
gout  and  much  splenic  pain.  Left  axillary  glands  much  enlarged.  Urine  I.OIO 
with  trace  of  albumen.     (Patient  lost  sight  of  afterwards.) 


10.— Gout  in  Relation  to  Purpura. 

Purpura  may  be  associated  with  gout,  as  in  the  following  case, 
which  was  under  my  care  some  years  ago.  It  affords  an  illustra- 
tion of  hemorrhagic  tendency  supervening  in  a  man  of  strongly 
developed  gouty  diathesis  under  the  influence  of  privation. 

A  Case  of  Purpura  Hcemorrhagica  in  a  Gouty  Man. 
Reported  by  Mr.  Sydney  Dayies,  B.A.,  M.B. 

Frederick  C,  set.  forty-four,  brushmaker,  was  admitted  to  St.  Bartholomew's  Hos- 
pital on  the  1 6th  of  August.  He  presented  the  appearance  of  a  well-nourished  man 
of  moderate  size. 

The  patient  gave  the  following  history  : — He  had  enjoyed  very  good  health  up  to 
the  last  five  years.  About  that  time  he  became  subject  to  gout,  of  which  he  has  had 
since  then,  several  attacks  in  the  feet,  knees,  and  left  hand  respectively  ;  the  index, 
middle,  and  little  finger  had  twice  been  the  seat  of  the  disease,  the  last  occasion  being 
only  three  weeks  ago,  and  the  pain  in  the  index  and  little  finger  remains  at  the  pre- 
sent time. 

Contemporaneously  with  the  last  attack  of  gout  {i.e.,  three  weeks  ago)  he  was 
seized  with  pain  in  the  neck,  which  was  followed  at  the  end  of  a  fortnight  by  a 
swelling  in  the  right  posterior  cervical  triangle.  This  swelling  had  increased  pro- 
gressively till  the  present  time.  The  day  before  admission  he  noticed  that  he  was 
covered  all  over  the  body  with  purpuric  spots,  but  chiefly  on  the  legs.  Since  the 
morning  of  the  day  on  which  he  was  admitted,  he  has  had  severe  epistaxis.  At  the 
same  time  that  the  tumour  disappeared  in  the  neck  his  voice  became  hoarse,  and  had 
remained  so  ever  since.  He  had  been  unable  to  work  for  five  weeks,  and  for  the  last 
three  weeks  had  taken  very  little  food.      He  had  been  an  average  drinker.     The 


200   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

family  history  had  been  one  of  gout  on  the  mother's  side,  herself,  her  father,  and  two 
sons  having  been  affected  with  it. 

On  admission  the  patient  had  a  sallow  complexion  and  a  very  hoarse  voice.  In 
the  lower  part  of  the  posterior  cervical  triangle  of  the  right  side  there  was  a  firm, 
hard,  immovable  tumour,  about  the  size  of  half  an  orange,  and  of  a  dark  colour  ;  the 
tumour  was  well-defined,  and  exhibited  fluctuation  and  pulsation  ;  it  was  painful,  even 
when  not  handled.  His  body  was  covered  with  purpuric  spots,  which  were  most 
numerous  on  the  legs.  The  lungs  and  heart  presented  no  marked  abnormality.  The 
urine  was  acid,  and  contained  a  trace  of  phosphates,  but  no  albumen.  His  evening 
temperature  was  102°.  Neither  the  liver  nor  spleen  was  found  to  be  increased  in 
size. 

The  following  notes  will  best  indicate  the  progress  of  the  disease  : — 

August  17th. — No  pulsation,  and  less  pain  in  the  cervical  tumour  ;  morning  temp. 
99°,  evening  temp.  100.90.  The  patient  less  feverish.  Did  not  sleep  well.  Tongue 
fairly  clean. 

1 8th. — A  few  purpuric  spots  have  appeared  on  the  tongue,  those  on  the  body  are 
fading.  The  patient  has  a  good  deal  of  irritation  about  the  larynx,  which  kept  him 
awake  during  the  night.  Pain  and  tenderness  on  percussion  at  a  spot  about  two 
inches  below  the  left  clavicle.  Pulse  intermittent.  Temp.  98.8°  and  99.4°  respec- 
tively.    Haematuria ;  gums  spongy. 

19th. — Patient  does  not  feel  so  well ;  more  feverish.  Soreness  of  throat.  Tongue 
thickly  coated  with  brown  fur  ;  oozing  from  gums.  The  tumour  has  assumed  a  dusky 
greenish  hue.  Urine  nearly  black  with  thick  sediment,  giving  blood-reaction  ;  con- 
tains one-sixth  albumen.  Spots  on  legs  fainter.  Pulse  very  feeble.  Morning 
temp.  98. 8°,  evening  101.20. 

20th.  — Haemoptysis.  Tongue  cleaner ;  the  purpuric  spot  is  ulcerating ;  gums 
bleeding.  Tumour  less  tender,  greenish-blue  colour.  Nausea,  appetite  worse,  great 
thirst.  Pain  in  testicles  and  bladder,  more  severe  in  the  latter  before  and  after 
making  water.  Haematuria  increased.  Pulse  variable,  very  weak  and  frequently 
intermittent.     Heart-sounds  very  feeble.     Morning  temp.  99. 20,  evening  100.60. 

2 1st. — Feels  very  weak,  appetite  increased,  voice  clearer,  less  cough.  Temp, 
morning  99.6°,  evening  100°. 

22nd. — Temp,  morning  99.4°,  evening  101.8°. 

23rd. — No  cough,  voice  improved.  Haemorrhage  from  gums  less.  Tongue  clean. 
Sediment  of  urine  seen  under  the  microscope  to  contain  red  blood-corpuscles.  Some 
blood  from  the  finger  was  also  examined  by  the  microscope,  and  found  to  contain  an 
excess  of  white-blood  cells.     Temp,  morning  102°,  evening  100.8°. 

24th. — Patient  very  pallid  and  weak,  feverish,  and  thirsty.  No  haemoptysis,  and 
less  haemorrhage  from  the  gums.  The  swelling  in  neck  has  become  more  diffluent. 
Haematuria  has  diminished,  and  albumen  has  disappeared  from  the  urine.  Temp, 
morning  102.6°,  evening  101.40. 

25th. — Pulse  124.  Patient  thirsty,  and  takes  food  well.  Has  passed  eight  pints 
of  water  in  twenty-four  hours.     Temp,  morning  100.60,  evening  101.6°. 

26th. — Pulse  134,  regular.  Patient  feels  better.  Tongue  coated,  rather  tremu- 
lous. Bowels  confined  ;  flatulent  distension  of  abdomen.  Takes  food  fairly  well.  Very 
anaemic.  Has  passed  seven  pints  of  urine,  of  natural  colour.  A  few  large  petechiae 
on  the  abdomen.     Temp,  morning  99°,  evening  100.6°. 

27th. — Great  dyspnoea  ;  no  cough  ;  no  pain  in  the  chest.  Tongue  cleaner  ;  bowels 
open  twice.  Abdomen  distended,  tympanitic.  Vomiting.  Pulse  intermittent. 
Respirations  46.     Morning  temp.  99. 6°. 

The  patient  died  in  the  middle  of  this  day. 

Treatment. — An  ice-bag  was  applied  to  the  blood-tumour  in  the  neck,  and  appeared 
to  stop  its  increase  and  cause  its  resolution.  The  general  treatment  included  the  use 
of  fresh  vegetables,  of  remedies  such  as  ergot,  ice,  and  other  styptics,  but  no  treat- 
ment appeared  to  materially  influence  the  course  of  the  disease. 

A  post-mortem  examination  was  made,  and  gave  the  following  results  :— 


HEMOPHILIA.  20 1 

There  were  small  subcutaneous  haemorrhages  on  the  front  of  the  thighs  and  abdomen. 
Haemorrhages,  about  the  size  of  balf-a-crown,  were  found  on  the  under  surface  of  the 
dura  mater,  to  the  right  of  the  median  line  near  the  vertex.  There  was  a  patch  of 
dark  staining  on  the  anterior  surface  of  the  heart,  and  some  small  haemorrhages 
beneath  the  endocardium  of  the  left  ventricle.  The  intestines  were  much  distended 
with  gas,  and  contained  greenish-black,  pultaceous  faeces.  No  spots  of  haemorrhage 
were  seen  in  the  stomach  or  intestines.  Spleen  and  liver  were  normal.  The  pelves 
of  both  kidneys  were  darkly  stained,  and  a  little  blood  could  be  scraped  from  the 
mucous  membrane.  The  bladder  exhibited  one  or  two  spots  of  extravasated  blood 
near  the  neck.  The  cervical  tumour  was  found  to  contain  an  accumulation  of  reddish 
fluid  matter,  probably  the  result  of  altered  blood-extravasation. 

Hsematinuria. — In  one  case  of  paroxysmal  hasmatinuria  in  a 
man  under  my  care,  an  attack  of  gout  occurred. 

11.— Gout  in  Relation  to  Haemophilia. 

A  connection  between  gout  and  this  variety  of  the  hemorrhagic 
diathesis  has  been  affirmed  by  various  observers  for  sixty  years 
past.  Most  modern  writers  on  the  subject  of  haemophilia  deny, 
or  attach  little  importance  to,  such  a  connection.  According  to 
Legg,1  true  gout  is  extremely  rare  amongst  those  who  thus  suffer, 
and,  as  he  points  out,  this  is  readily  conceivable  because  of  the 
youth  of  the  majority  of  the  patients. 

The  fact  that  the  joints  may  suffer  specifically  in  haemophilia 
has,  no  doubt,  been  one  reason  for  the  belief  that  there  is  a  gouty 
element  in  such  cases. 

It  is,  however,  certain  that  history  of  true  gout,  and  phases  of 
incomplete  gout,  may  be  met  with  in  the  ancestors  of  some  of 
these  patients. 

In  analyzing  the  cases,  seven  in  number,2  reported  by  Legg,  I 
find  the  following  facts  bearing  on  this  point :— Case  I.  The 
maternal  grandmother  was  subject  to  gravel  in  the  kidneys,  and 
had  passed  several  small  stones.— Case  2.  A  brother  of  the  patient, 
aet.  twenty-five,  is  stated  to  have  had  "  chalk-stones  up  the  sides 
of  his  feet." 3  The  father  and  his  relations  were  gouty.  One 
paternal  uncle  was  gouty.  Case  5.  Father  had  chalk-stones  in 
the  hands,  and  all  his  family  were  subject  to  gout. 

The  disease  is  markedly  hereditary,  being  handed  down  by  the 
females  to  the  males,  who  are  the  chief  sufferers.  Females  suffer 
rarely,  and  only  in  mild  degree  from  it,  the  joints  not  being,  as  a 
rule,  the  seat  of  effusion,  but  only  of  pains.  Menorrhagia  may  be 
the  only  expression  in  a  female  bleeder.      Amongst  determinants 

1  A  Treatise  on  Hasmophilia,  1872. 

2  One  in  Path.  Soc.  Trans.,  vol.  xxxiii.  ;  one  ibid.  vol.  xxxvi.  ;  and  five  in  his 
monograph. 

3  Tophaceous  gout  sometimes  occurs  early  in  life. 


202   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

of  attacks  of  hemorrhage  in  these  cases,  apart  from  traumatism 
of  every  degree,  are  exciting  or  depressing  emotions,  sudden  varia- 
tions of  climatic  condition,  and  exposure  to  cold  and  damp. 

The  attacks  are  preceded  by  euphoria,  as  is  the  case  often  in 
epilepsy  and  gout. 

Articular  attacks  with  effusion  of  blood  into  the  joint  induce, 
or  are  associated  with,  pyrexia,  which  may  reach  104°  or  1050. 
In  1829  Bieken  (quoted  by  Legg)  described  haemophilia  as  an 
anomalous  variety  of  gout,  and  asserted  that  (1.)  the  tendency  to 
extreme  haemorrhages  has  been  of  late  observed  only  in  those 
persons  whose  parents  or  grandparents  have  suffered  from  gout ; 
(2.)  in  those  members  of  "  bleeder  "  families  who  have  escaped  the 
tendency  to  haemorrhage,  gouty  paroxysms  may  often  be  observed  ; 
(3.)  in  bleeders  themselves  gouty  paroxysms  are  nearly  always 
seen,  and  sometimes  an  alternation  of  the  joint-affection  with  the 
bleeding ;  (4.)  gout  is  a  disease  which  stands  in  a  very  close 
relation  to  the  blood  and  blood-vessels,  and  often  appears  to  be  a 
direct  cause  of  haemorrhage. 

Legg  disputes  each  of  these  propositions,  but  I  cannot  agree 
with  his  reasoning.  I  do  not  regard  it  as  probable  that  all  cases 
of  haemophilia  can  be  traced  to  ancestral  gouty  influence  alone  ; 
but  the  occurrence  of  gouty  history,  so  far  as  already  proven, 
appears  to  me  too  important  a  factor  in  the  aetiology  of  the  dis- 
order to  be  quite  disregarded.  The  difficulty  of  securing  trust- 
worthy history  of  true  gout  in  any  ancestry  is  not  slight,  and  is 
especially  great  in  the  case  of  patients  of  hospital  rank.  Bieken 
probably  regarded  the  painful  and  tumid  joints  of  active  haemo- 
philia as  examples  of  gouty  arthritis.  To  dispute  the  fourth  pro- 
position, as  does  Legg,  by  affirming  that  in  fifty  cases  of  well- 
marked  gout  he  found  not  more  than  three  who  had  suffered 
from  haemorrhoids,  and  none  who  had  had  bleedings,  appears  to 
me  unwarrantable,  since  the  subjects  of  regular  gout  are  seldom 
those  who  suffer  from  its  incomplete  manifestations,  amongst 
which  are  haemorrhoids  and  haemorrhagic  tendency.  I  should 
not  expect  to  find  a  coalescence  of  regular  gout  with  haemophilia. 
Bleedings  are  not  frequent  in  true  gout,  but  are  common  enough 
as  part  of  the  general  gouty  habit,  and  more  markedly  so  in 
females. 

If  regard  be  had  to  some  of  the  leading  features  of  gout  and 
of  haemophilia,  a  conviction  arises  that  there  is  an  alliance  or  a 
degree  of  relationship  between  the  two  states.  We  may  set  out 
by  way  of  parallel  the  following  points  relating  to  each  dis- 
order : — 


HEMOPHILIA. 


203 


Gout. 
Heredity  strongly  marked. 

Females  much  less  affected. 

Females  less  liable  to  overt  gout ;  bear 
gouty  sons. 

Attacks  sudden,  paroxysmal. 

Attacks  preceded  by  euphoria. 

Determinants  traumatic,  climatic,  psy- 
chical, dietetic. 

Antecedent  cumulative  plethora. 

Predilection  for  joints.  Arthritic  dia- 
thesis. 

Arthritis  leading  to  degeneration  of 
cartilage  with  specific  deposits,  anky- 
losis, synostosis. 

Chronic  skin-diseases  associated. 

Haemorrhagic  tendency  in  incomplete 
gout,  as  met  with  in  descendants  of 
the  gouty. 

Tendency  to  recurrence  of  attacks,  arti- 
cular and  other. 

Alternation  of  articular  attacks  with 
other  abarticular  manifestations. 

Epilepsy  occasionally  associated. 

By  way  of  contrast  we  may  set  out  the  following  points  in 
the  two  disorders  : — 


H/EMOPHILIA. 

Heredity  strongly    marked,  also,  gouty 

heredity  not  seldom. 
Females  much  less  affected. 
Females  less  liable,  bear  sons  who  bleed. 

Attacks  sudden,  paroxysmal. 

Euphoria  preceding  attack. 

Determinants  traumatic,  climatic,  psy- 
chical. 

Antecedent  cumulative  plethora. 

Predilection  for  joints,  the  larger  more 
particularly ;  sometimes,  great  toe- 
joint  affected.  Arthritic  predisposition. 

Arthritis  with  degeneration  of  cartilage, 
fibrous  ankylosis. 

Chronic  skin-diseases  associated. 
Hasmorrhagic  tendency. 


Tendency  to  recurrence  of  attacks,  arti- 
cular and  other. 

Alternation  of  articular  effusion  with 
free  haemorrhages,  e.g.,  hsematuria  or 
epistaxis. 

Epilepsy  occasionally  associated. 


Gout. 
Occurrence  in  middle  life,  as  a  rule. 
Largely  dependent  on  dietetic  causes. 
Smaller  joints  affected  more  often  than 

larger,    e.g.,  great  toe,   ankle,  knees, 

fingers,  elbow. 
Pyrexia  moderate  in  acute  attacks. 


HAEMOPHILIA. 

Occurrence  within  first  two  years  of  life. 
Not  directly  dependent  on  dietetic  causes. 
Larger  joints  affected  chiefly,  e.g.,  knee, 

ankle,  elbow,  shoulder,  hip  ;  the  digits 

rarely. 
Pyrexia  severe  when  joints  involved. 


Dr.  Barlow  has  related  to  me  a  very  noteworthy  case  in  which 
a  young  man  who  had  haemophilia  with  epistaxis,  hsematuria, 
and  effusions  into  the  joints,  became  the  subject  of  uratic  tophi  on 
the  ears. 

In  view  of  the  predominant  features  of  haemophilia,  it  is,  I 
believe,  hardly  possible  to  resist  the  conviction  that  there  is  a 
relationship  between  this  disorder  and  gout,  as  understood  in  its 
widest  sense.  We  are  certain  of  gouty  ancestry  in  a  goodly  pro- 
portion of  the  cases.  A  marked  characteristic  of  haemophilia  is 
the  tendency  to  recurrence.  It  would,  thus,  appear  that  the  dis- 
order is  allied  to  certain  recurrent  illnesses  which  grow  up  from 
time  to  time  till  by  accumulation  they  become  manifest.      Where 


204   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

the  bleeding  tendency  is  very  marked,  no  measure  of  precaution 
avails  to  avert  attacks.  This  is  so  with  gout.  A  safe  equilibrium 
is  then  only  maintained  with  difficulty,  and  very  slight  provoca- 
tions suffice  to  determine  outbursts  in  various  forms.  I  regard 
severe  hemophilia  as  a  gradually  cumulative  plethora,  which  must 
perforce  discharge  itself. 

I  therefore  agree  with  Hutchinson  that  a  possible  explana- 
tion of  this  peculiar  malady  is  to  be  found  in  peculiarities  of 
vascular  structure,  developed  originally  by  gout,  which  have  be- 
come modified  and  specialized  by  transmissions  through  many 
generations.  If  this  be  the  case,  it  is  intelligible  that,  in  the 
subjects  of  this  new  evolutionary  disorder,  we  do  not  often  find 
symptoms  of  overt  gout.  We  must  have  regard  to  the  type 
presented,  and  in  this  line  of  investigation  we  come  to  see  a  like- 
ness in  habit,  and  a  predilection  for  tissue  which  recalls  some  of 
the  recognized  manifestations  of  the  gouty  diathesis.  It  is  far 
from  uncommon  to  meet  with  hemorrhagic  histories  in  the  descen- 
dants of  the  gouty,  epistaxis  and  monorrhagia  in  severe  degrees 
being  perhaps  most  frequently  noted,  while  intracranial  and 
retinal  hemorrhage  are  less  so. 

Cases  of  sporadic  hemorrhagic  tendency  I  regard,  with  Hutch- 
inson, as  distinctly  and  closely  allied  to  the  graver  form  of  true 
hemophilia.1  A  study  of  sporadic  cases  of  any  disease  is  often 
strongly  suggestive,  and  helpful  to  a  better  comprehension  of  its 
etiology. 

It  would  nowadays  be  little  more  than  pedantry  to  deny  the 
relationship  of  certain  morbid  states  to  the  gouty  habit,  in  its 
widest  aspect,  because  one  cannot  place  one's  finger  on  a  tophus, 
or  demonstrate  sodium  urate  in  the  blood  of  the  affected  indi- 
vidual. This  is  assuredly  not  the  solitary  touch-stone  for  all 
ailments  owing  dependence  on  an  original  gouty  state.  As  I 
have  already  had  occasion  to  remark,  there  are  many  perturba- 
tions in  gout  beyond  those  of  uric  acid,  and  many  associated 
profound  tissue-changes.  It  is  not  hard  to  conceive  that  some 
only  of  these  variously  impressed  textural  characters  may  be 
transmitted,  and  passed  on,  too,  with  variations,  so  that  new 
evolutionary  phases  of  disease  come  to  be  manifested  in  the 
remote  descendants  of  those  goutily  disposed. 

As  with  gout,  so  with  hemophilia,  the  nervous  system  is 
markedly  involved ;  thus,  the  determination  to  the  joints  and  the 
occasional  paroxysmal  features  of  the  disorder  afford,  amongst 
other  symptoms,  indications  of  its  specific  influence. 

1  Pedigree  of  Disease,  p.  25. 


TRAUMATISM.  205 

Instances  are  not  wanting  in  which  associated  instability 
of  the  nervous  system  in  haemophilia  has  been  declared  by 
epilepsy. 

12.— Relation  between  Gout  and  Traumatism. 

I  have  already  stated  that  gout  may  supervene  in  paroxysmal 
form  in  those  goutily  predisposed,  as  a  result  of  shocks  and  inju- 
ries. Many  instances  are  on  record.  Thus,  a  fall  from  a  horse 
may  determine  an  attack.  Sprains  of  joints  may  evoke  gout  in 
them.  The  shock,  mental  and  bodily,  of  even  minor  surgical  opera- 
tions may  be  provocative ;  thus,  removal  of  tumours,  of  a  tooth, 
ligature  of  piles,  operation  for  cataract,  and  so  trifling  an  irritant, 
according  to  Heberden,  as  a  gnat-bite.1  Vaccination  has  been 
known  to  induce  a  paroxysm  in  a  man  aged  fifty.  Paget  has 
known  a  patient  suffer  a  sharp  attack  after  each  of  three  opera- 
tions which  he  had  undergone.  Operating  surgeons,  certainly  in 
London,  are  familiar  with  such  cases.  The  great  toe-joint,  being 
much  exposed,  is  often  the  site  of  gout  from  injuries  almost 
unnoticed  at  the  time  of  infliction,  and  if  the  attack  be  a  primary 
one,  it  is  often  attributed  to  the  injury  alone.  Tight  boots  may 
be  the  cause.  The  part  injured  may  not  be  the  site  of  the  attack, 
the  gouty  process  fixing  on  some  other — by  preference  a  joint. 
Parts  much  used  are  especially  liable  to  attack,  as  the  ball  of  the 
thumb,  wrist,  knees  and  feet  of  riders,  and  the  soles  in  painters 
and  those  working  on  ladders. 

Parts  once  injured  may  long  afterwards  become  the  elective 
seat  of  gout.  Phlebitis  may  occur  in  the  saphenous  vein  and  tribu- 
taries of  the  external  popliteal  vein  from  friction  of  stirrup-leathers, 
and  renewed  attacks  may  be  experienced  in  the  same  veins  at  later 
periods  without  fresh  provocation. 

"  Nothing,"  remarks  Sir  James  Paget,  "  can  show  better  than 
gout  sometimes  does  how  exactly  health  is,  in  some  persons,  just 
maintained  ;  how  nearly  balanced  in  them  are  health  and  disease, 
comfort  and  misery.  A  person  on  whom  I  could  rely  assured  me 
that  within  five  minutes  after  breaking  his  forearm,  while  he  was 
in  what  he  thought  good  health,  he  had  an  attack  of  gout  in  his 
hand." 2 

Severe  haemorrhages,  as  hsematemesis  or  epistaxis  (trauma- 
tismes  internes),  sometimes  lead  by  the  shock  which  they  occasion 

1  "  Idem  quoque  interdum  evenit,  ubi  membrum  ab  arthritide  jam  convalescens 
ictu  aliquo,  aut  distortione,  aut  etiam  culicis  punctione,  leesum  fuerit."—  De  Arthritide. 

2  Clin.  Lect.  and  Essays,  p.  354. 


206      RELATION    OF   GOUT    TO    OTHER   MORBID    STATES. 

to  paroxysmal  goaty  attacks.  A  blow  on  a  given  part  in  a  gouty 
person  has  been  followed  by  the  formation  there  of  tophus.  Tight 
boots  have  been  blamed  for  determining  gout  in  the  great-toes 
of  our  immediate  ancestors,  but  podagra  existed  classically  when 
sandals  were  worn. 

It  is  noteworthy  that  the  same  kind  of  vulnerability  is  met 
with  in  some  persons  of  rheumatic  predisposition.  Monarthritis 
may  follow  injury  to  a  joint,  and  determine,  reflexly  or  otherwise, 
the  spread  of  multiple  rheumatic  arthritis,  illustrating  the  common 
basal  arthritic  diathesis  in  both  cases. 

It  thus  appears  that  goutily-disposed  persons  are  often  very 
vulnerable  in  their  textures,1  and  this  peculiar  sensitiveness  exists 
as  a  part  of  the  specific  nature  of  the  malady  when  once  esta- 
blished in  the  system.  The  original  injury  would  appear  to 
lower  the  tissue-vitality,  and  render  it  a  specially  susceptible 
part,  a  locus  minoris  resistentice. 

Such  trophic  change  is  also  well-known  to  be  one  of  the  de- 
termining factors  in  the  localization  of  new  growths,  and,  in 
particular,  of  malignant  tumours. 

It  cannot  be  doubted  that  any  prevailing  habit  of  body  exerts 
an  influence  on  the  repair  of  injuries  and  wounds  in  the  indivi- 
dual affected.  Hence,  traumatic  conditions  are  apt  to  be  modified 
in  the  subjects  of  gout.  Injuries  to  joints  are  thus  recovered 
from  tardily. 

According  to  Paget,  when,  in  a  patient  of  middle  or  later  age, 
an  injured  joint  does  not  recover  in  due  time,  gout  may  be  sus- 
pected. The  reparative  process  in  a  wound  or  bony  fracture  may 
be  temporarily  arrested  by  an  attack  of  gout  in  the  part ;  on  its 
subsidence,  healing  may  proceed  quite  favourably. 

The  influence  of  gouty  cachexia  on  traumatism  is  that  which 
pertains  to  any  cachectic  state.  The  presence  of  anasmia  or 
glychaBmia,  cirrhosed  and  inadequate  kidneys,  thickened  arteries, 
and  the  low  vital  power  thus  entailed,  will  suffice  to  explain  the 
facts  that  wounds  in  such  subjects  often  heal  slowly,  perhaps 
bleed  unduly,  or  are  prone  to  low  septical  or  erysipelatous  inflam- 
mations. 

The  susceptibility  of  the  skin  to  certain  irritants,  as  arnica  and 
iodine,  has  been  specially  noted  in  persons  of  gouty  disposition, 
and  must  be  considered  in  relation  to  treatment  by  such  appli- 
cations. 

The  influence  of  shock,  either  mental  or  bodily,  in  precipitating 

1  "  Persons  thus  combustible  are  not  rare.    You  may  liken  them  to  lucifer  matches  ; 
gout  explodes  in  them  whenever  they  are  roughly  handled." — Paget. 


OSTEITIS   DEFORMANS.  2CJ 

a  paroxysmal  attack  of  gout,  illustrates  as  well  the  unstable 
neurotic  element  present  in  gouty  persons  as  the  tissue-pecu- 
liarity. No  mere  humoral  conception  of  the  disorder  suffices  to 
explain  some  of  its  most  marked  features.  The  effects  of  injury 
or  of  operation  tell  both  locally  on  the  part  and  centrally  on  the 
nervous  system,  and  the  explosive  result  may  be  manifested  either 
in  the  damaged  texture,  or  at  some  distant  part  which  may,  or 
may  not,  be  reflexly  related. 


13.— Gout  and  Osteitis  Deformans. 

The  peculiar  disease  of  the  bony  skeleton  to  which  the  term 
"  osteitis  deformans  "  was  applied  by  Paget  has  been  met  with  in, 
perhaps,  the  majority  of  instances  in  persons  of  gouty  habit  or 
inheritance.  Paget  declares  that  this  disease  "  has  appeared  in 
no  usual  relation,  whether  by  inheritance  or  coincidence,  with  any 
other  disease  except  gout."  1 

By  the  kindness  of  Dr.  Barlow,  I  am  enabled  to  append  the 
notes  relating  to  a  case  of  osteitis  deformans  in  which  gouty 
symptoms  and  uratic  deposits  occurred. 

Rev.  Mr.  X.,  aged  sixty.  First  seen  by  me  August  II,  1885.  Gave  history  of 
maternal  grandfather  having  had  gout.  Patient  himself  had  had  several  attacks  of 
monarticular  gout  (big-toe).  Gets  pains  in  knees  and  feet  if  he  walks  much,  but  has 
felt  necessity  of  exercise,  and  for  several  months  has  ridden  a  tricycle  with  advantage 
to  general  health.  Two  months  before  I  saw  him  had  suffered  from  some  sharp 
pains  on  left  side  of  chest,  with  short  breath.  Relieved  by  leeches,  and  able  to  be 
about  in  one  week.  Consulted  me  now  on  account  of  breath  being  short,  and  a  little 
skin-eruption. 

Condition,  August  II,  1885. — Rather  square-set,  well-built  man.  Fair  general 
nutrition.  Left  metatarso-phalangeal  joint  a  little  thickened ;  no  tenderness  now. 
Both  legs,  osteitis  deformans  ;  right  presents  general  bowing  outwards,  and  tibia 
is  slightly  but  definitely  thickened.  No  tenderness,  and  no  separate  node.  The 
bowing  and  thickening  quite  different  from  old  rickets.  The  left  leg  also  bowed  out 
slightly,  but  no  definable  thickening.  Bone-ends  not  obviously  altered  ;  joint  move- 
ments free. 

No  other  osseous  abnormality. 

Slight  chronic  eczema  on  both  legs,  and  a  little  over  sacrum. 

Lungs — a  little  wheezing  at  bases. 

Heart-sounds  natural.     Pulse  not  hard.     Brachial  artery  not  tortuous. 

Tongue  nearly  clean.     False  teeth. 

No  tophi. 

Urine  high-coloured.     No  albumen  ;  no  sugar. 

I  saw  him  next  on  March  30,  1886.  There  was  then  a  very  little  puffiness  under 
the  eyes.  He  was  complaining  again  of  his  bronchitis,  though  there  was  only  a  little 
rhonchus  to  be  heard. 

1  Med.-Chir.  Trans.,  vol.  Ixv.  p.  235,  1882. 

Vide  vol.  lx.  p.  37,  1877,  for  original  account  of  the  disease.  Cases  are  related  in 
both  communications. 


2o8       RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 

Next  note  is  on  March  7,  1887.  He  was  then  just  recovering  from  a  bad  attack 
of  gout,  from  which  he  had  suffered  for  one  month.  Both  feet  had  been  affected  and 
some  of  the  finger-joints.  There  was  a  little  oedema  of  the  dorsum  of  each  foot  still 
present,  though  no  heat  or  redness.  The  bronchitis  and  eczema  had  gone.  His  pulse 
was  a  little  intermittent.     Urine  clear,  dark-coloured,  free  from  albumen.    No  tophi. 

Next  note,  April  5,  1888.  Complains  of  irritation,  especially  below  the  scrotum 
and  in  the  perineum.     There  is  a  very  little  eczema  there. 

Tongue  clean. 

Urine  dark-coloured.     No  deposit  ;  no  albumen  ;  sp.  gr.  1.015. 

Now  an  undoubted  tophus  on  edge  of  left  helix,  and  (query)  commencing  small 
tophi  on  the  edge  of  right  lower  eyelid. 

My  impression  is  that  the  bowing  of  the  legs  is  slightly  more  marked  than  when 
he  first  presented  himself,  but  the  limb-condition  is  attended  with  very  little  discom- 
fort.    He  can  walk  fairly  on  the  level.     General  nutrition  maintained. 


14.—  The  Influence  of  the  Gouty  Habit  on  Specific  Febrile 
and  Acute  Diseases. 

There  is  little  knowledge  respecting  the  modification  of  specific 
febrile  states  or  of  acute  diseases  by  gouty  influence.  In  the 
young  this  habit  is  seldom  detectible,  or  but  rarely  presents 
suggestions  of  its  presence.  Hence,  it  is  not  possible  to  gain 
trustworthy  evidence  of  any  peculiarities  attaching  to  the  offspring 
of  the  gouty  while  the  subjects  of  the  exanthemata  or  of  acute 
disease. 

My  own  experience  fully  accords  with  that  of  Murchison,  who 
taught  that  persons  of  the  "  lithic  acid  dyscrasia,"  or  lithsemic 
subjects,  are  more  than  others  prone  to  ordinaiy  febrile  colds, 
and  to  unusually  severe  local  inflammations.  The  gouty  habit 
predisposes  to  local  inflammations  either  by  inherited  tissue- 
peculiarities^  or  because  of  the  altered  blood-condition  which  may 
supervene  from  time  to  time. 

Diphtheria. — Without  doubt,  such  tolerance  as  is  exhibited  by 
the  gouty  in  later  life  under  the  ordeal  of  acute  disease  will 
depend  largely  upon  the  structural  condition  and  functional  ade- 
quacy of  the  kidneys.  In  this  connection  the  following  case  of 
diphtheria,  recorded  by  Pye-Smith,  is  of  interest.  It  was  that 
of  a  man,  aged  forty-five,  who  died  of  ursemic  eclampsia  and  coma, 
and  whose  kidneys  together  weighed  only  five  ounces.  While  in 
Guy's  Hospital  he  was  attacked  with  diphtheria,  and  recovered, 
though  he  was  before  suffering  from  gout  and  albuminuria. 

Typhus  Fever — In  respect  of  typhus  fever,  the  gouty  habit  is, 
according  to  Murchison,  a  very  serious  complication.  He  never 
knew  a  gouty  person  attacked  with  typhus  recover.  The  risk  is 
that  of  unsound  kidneys,  which  always  prevent  recovery  from  this 
disease,  and  the  fact  is  perhaps  to  be  taken  along  with  that  relat- 


PNEUMONIA.       ERYSIPELAS.  209 

ing  to  the  age  at  which  typhus  hills,  since  persons  over  fifty  years 
almost  always  die  from  it. 

Pneumonia. — When  pneumonia  occurs  in  the  gouty,  it  is  not 
seldom  itself  a  gouty  manifestation,  and  is  not  so  fatal  as  might 
be  expected.  Its  onset  and  its  disappearance  may  be  somewhat 
sudden,  and  it  may  sometimes  be  plainly  relieved  by  other  gouty 
manifestations.  The  condition  of  the  kidneys  and  other  textures — 
no  less  than  the  age  of  the  patient — determines  the  gravity  in  each 
case.  If  there  be  already  present  emphysema  with  chronic  bron- 
chitis in  a  gouty  person  attacked  with  pneumonia,  the  prognosis 
is  rendered  as  grave  as  possible.  Emphysematous  lungs  are  com- 
monly intolerant  of  the  stress  of  acute  lobar  inflammation.  An 
"  arthritic "  pneumonia  is,  however,  less  likely  to  be  fatal  than 
other  forms. 

Erysipelas. — Prout  believed  that  erysipelas  was  unfavourably 
influenced  by  the  gouty  habit.  He  refers,  however,  to  cases  of 
gouty  glycosuria  occurring  in  middle  life,  where  there  is  probably 
an  enfeebled  state  of  body.  Dr.  Gregory,  of  Edinburgh,  observed, 
and  I  have  noted  the  same,  that  the  daughters  of  gouty  men  were 
particularly  liable  to  attacks  of  erysipelas.1  Scudamore  2  also  noted 
this,  and  remarked  that  erysipelas  appeared  to  represent,  or  come 
instead  of,  the  expected  fit.  Dr.  Copland 3  mentioned  amongst 
predisposing  causes  the  gouty  diathesis.  In  the  case  of  erysipelas, 
as  in  that  of  typhus  fever,  the  gravity  in  any  gouty  patient  is 
almost  certainly  in  relation  to  the  general  state  of  nutrition  and 
the  adequacy  of  the  kidneys.  In  low  states  of  health  the  poison 
of  erysipelas  is  certain  to  work  in  malignant  fashion,  and  it  is 
under  such  conditions  that  spontaneous  gangrene  sometimes  occurs 
in  the' subjects  of  gouty  cachexia  with  bad  arteries,  even  when 
glycosuria  is  not  a  dominant  feature. 

It  must  be  exceedingly  rare  for  paroxysmal  gout  to  occur  at 
the  same  time  with  acute  diseases.  As  the  exanthemata  are  met 
with  chiefly  in  the  earlier  decades  of  life,  it  is  very  unlikely  that 
such  a  combination  or  coincidence  should  arise. 

A  touch-stone,  as  it  were,  for  arthritic  and  other  habits  of 
body  is  sometimes  forthcoming  in  the  sequelas  of  fevers  and  various 
acute  illnesses.  Thus,  after  enteric  fever  there  may  be  subacute 
arthritis,  also  venous  thrombosis.  In  such  cases  I  have  some- 
times ascertained  arthritic  heritage  or  proclivity. 

1  Sir  Robert  Christison  informed  me  of  this. 

2  Op.  cit.,  p.  531.  3  Diet,  of  Medicine, 


2IO      RELATION    OF    GOUT    TO    OTHER   MORBID    STATES. 


15.— Influence  of  Gouty  Habit  on  Painful  Affections. 

It  is  certain  that  gout  often  aggravates  the  painfulness  of 
painful  processes.  It  may  affix  a  paroxysmal  character  to  them. 
The  gouty  have  commonly  undue  sensitiveness,  and  suffer  more 
than  others  from  ordinary  sources  of  pain. 

One  of  the  leading  ideas  about  gout  anywhere  is  its  painfulness. 
Were  gout  nothing  more  than  a  mere  inflammatory  process,  or 
goutiness  but  discomfort  without  pain,  it  would  disturb  its  victims 
far  less  than  is  usually  the  case.  But,  in  truth,  most  of  the  mani- 
festations of  gout  are  painful,  and  some  exceedingly  so.  This  is 
part  of  its  specific  character.  A  joint  acutely  involved  by  rheu- 
matism is  commonly  but  little  painful  unless  it  be  moved  or 
handled.  A  gouty  arthritis  is  exquisitely  painful  when  absolutely 
at  rest.  Those  who  have  suffered  both  from  rheumatism  and  gout, 
or  who  in  the  course  of  a  single  illness  have  attacks  of  each  (in  a 
truly  commingled  case),  can  clearly  distinguish  the  respective 
pains  of  each.  A  notable  instance  of  this  kind  was  once  under 
my  care,  and  the  man  could  tell  at  any  time  whether  he  was  more 
gouty  or  more  rheumatic. 

The  pain  in  gout  is  disproportionate  to  the  apparent  degree 
of  arthritis.  This  fact,  I  conceive,  tends  to  show  that  there  is 
a  special  nervous  erethism  in  the  gouty.  They  all  bear  pain 
badly.  Response  to  every  source  of  irritation  is  heightened, 
not,  I  believe,  by  the  manifestations  of  the  disease,  but  by  the 
essential  nature  of  the  malady.  Such  persons  as  are  gouty  would 
not  be  so  if  they  did  not  possess,  as  part  of  their  innate  nervous 
disposition,  a  specially  intensified  susceptibility,  and  a  tendency 
to  explosive  neurotic  manifestations. 

Paget  tells  of  a  pyasmial  abscess  which  was  very  painful  in  a 
gouty  man,  and  he  believes  that  some  cases  of  cancer  are  rendered 
specially  painful  by  inflammations  in  goutily  disposed  persons. 

Great  painfulness  attaches  to  even  simple  disturbances  in  the 
gouty.  Not  to  mention  here  the  agonising  neuralgias  due  to 
gout,  it  may  suffice  to  recall  the  special  sensory  disturbances 
attaching  to  the  skin-diseases  dependent  on  this  habit,  the  pains 
of  indolent  furuncles,  those  deep-seated  pains  in  the  heel,  sole, 
coccyx,  muscles,  tongue,  teeth,  and  ensiform  cartilage,  and  the 
incoercible  cramps  of  the  calves  met  with  in  the  gouty.  All 
these  may  be  unduly  severe,  and  some  of  them  agonising.1 

1  Professor  Ball,  of  Paris,  has  recorded  the  case  of  a  gouty  patient  who  never  had  a 
pain  anywhere,  however  transient,  without  a  tophus  immediately  forming  there. 


PYEMIC   ARTHRITIS   AND    GOUT.  2  I  I 

16.— Pysemic  Arthritis  and  Gout. 

Pyeemia  may,  sometimes,  supervene  in  gouty  as  in  other  per- 
sons, and  the  attendant  phenomena  may  prove  puzzling.  It  is 
easy  to  be  wise  after  the  event,  but  in  some  cases  pyaemia  may 
arise  insidiously  from  a  very  small  and  latent  purulent  focus,  and 
set  up  articular  inflammations,  which  it  is  only  too  easy  to  consider 
as  "  rheumatic  "  or  "  gouty  "  in  the  subjects  of  arthritic  proclivity. 
There  may  be  severe  pyrexia,  which  is  greater  than  obtains  in 
any  form  of  true  gout,  but  there  may  also  be  absence  of  any 
characteristic  rigors,  and  of  high  flights  of  temperature.  The 
diagnosis  is  not  difficult  if  the  latter  should  occur. 

Cystitis  and  suppurative  foci  may  arise  insidiously  in  the  sub- 
jects of  chronic  gout,  and  with  some  frequency  in  cases  of  chronic 
glycosuria  with  cachexia. 

At  the  autopsy  in  such  cases  may  sometimes  be  found,  together 
with  the  presence  of  pus  in  the  articulations,  kidneys,  &c,  old 
changes  in  joints  due  to  gout,  to  wit,  erosion  of  cartilages  and 
encrustation  of  urates  with  ostitis.  There  is  commonly  little  to 
be  done  to  save  the  patient  in  these  malign  cases,  but  it  is  at 
least  proper  that  a  correct  diagnosis  should  be  made  during  life. 


The  subjects  discussed  in  this  chapter  respecting  the  influence 
of  gout  on  various  constitutions  and  diathetic  states  have  attracted 
much  attention  at  the  hands  of  French  physicians,  and  they  have, 
accordingly,  sought  to  classify  gout  under  several  varieties  or  types. 
These  have  not  been  commonly  accepted  by  British  authorities,  at 
all  events  in  modern  times,  with  the  exception,  perhaps,  of  Laycock. 

I  have  hesitated  to  adopt  this  teaching  of  the  French  school, 
and  preferred  to  treat  the  subject,  a  confessedly  difficult  one,  with 
less  definition  and  dogmatism. 

The  classification  of  Durand-Fardel  relates  to  gout  as  affecting 
those  of  sanguine,  bilious,  nervous,  and  lymphatic  constitution. 
Lecorche  describes  five  types  founded  on  the  predominant  localiza- 
tion of  the  disorder,  viz.,  articular,  nephritic,  muscular,  neuropathic, 
and  gastro-hepatic.  These  varieties  have  already  been  considered 
with  respect  to  the  several  tissues  and  organs  as  affected  by  gout. 

For  clinical  purposes  it  may  be  necessary  to  have  regard  to  the 
predominant  features  in  any  given  case  of  the  disorder,  but  in  all 
there  is  a  basic  unity  of  type.  The  important  point  is  to  recog- 
nize correctly  the  truly  gouty  element  in  any  case. 

In  practice  it  is   not   always  possible   to   fit   the  cases  to  the 


212   RELATION  OF  GOUT  TO  OTHER  MORBID  STATES. 

particular  types,  and,  indeed,  several  of  these  may  be  present  in  a 
single  individual. 

The  possibility  of  new  phases  of  gout,  as  of  other  diseases, 
arising  in  the  course  of  time  must  be  borne  in  mind.  By  varia- 
tion in  transmission,  by  coalescence  with  other  states,  and  by 
altered  modes  of  life  and  diet,  it  is  at  least  conceivable  that 
evolutionary  changes  may  occur  whereby  some  of  the  features  of 
this  disease,  hitherto  regarded  as  classical,  may  be  less  clearly 
marked,  or  even  disappear,  and  thus  new  forms  of  gouty  mani- 
festation may  come  before  future  observers.  Sir  James  Paget 
has  directed  attention  to  this  large  question,  and  in  respect  of 
gout  has  instanced  the  occurrence  of  phlebitis  as  a  possible  out- 
come of  variation  in  transmission. 

There  may  possibly  be  another  such  example  in  the  case  of 
subcutaneous  nodules,  which  certainly  were  formerly  unrecognized, 
and  appear  to  be  new  manifestations  of  the  arthritic  diathesis. 

In  considering  the  varied  possible  comminglings  of  gout,  it  must 
also  be  borne  in  mind  that  this  disorder  may  develop  in  persons 
owning  arthritic  heredity  in  very  varying  degree,  or  may  grow 
up  anew  in  persons  of  other  diathetic  habits.  Hence,  we  find  all 
varieties  of  goutiness  in  persons  who  present  no  obvious  physiog- 
nomical traits  of  the  disorder,  as  in  purely  nervous  or  spare  sub- 
jects whose  constitution  is  frail.  Amongst  these  are  examples  of 
"  poor,"  and  many  of  "  incomplete "  gout,  the  latter  including 
cases  of  visceral,  and  of  what  has  been  badly  termed  (as  I  think) 
"  nervous  gout."  The  disorder  is  perhaps  only  slightly  indicated 
in  some  member  of  a  gouty  family,  perhaps  a  female,  while  in  a 
more  robust  brother  it  appears  in  more  overt  and  vigorous  form. 

In  these  irregular  or  incomplete  cases  we  have  an  implantation, 
or  grafting,  of  the  gouty  on  other  diathetic  habits.  For  the  pur- 
pose of  successful  treatment  of  the  various  troubles  thus  arising 
it  is  important  to  recognize  this  coalescence. 

Holding  very  strongly,  as  I  do,  the  views  already  expressed  in  this  and  the  preced- 
ing chapters  respecting  the  wide  relationship  and  multiform  phases  of  gout,  I  must 
here  express  my  complete  dissent  from  the  following  passage,  which  occurs  in  the 
second  edition  (1888)  of  Fagge's  "Principles  and  Practice  of  Medicine,"  edited  by 
my  esteemed  and  very  able  friend,  Dr.  Pye-Smith  : — 

"  For  some  reason  it  has  become  common  to  ascribe  bronchitis,  dyspepsia,  gas- 
tralgia,  iritis,  gravel,  cystitis,  and  urethritis,  phlebitis,  eczema,  and  even  psoriasis,  to 
a  gouty  diathesis.  But  the  evidence  is  very  slight,  and  the  '  gout '  to  which  such 
evidence  as  there  is  applies  is  the  distillation  of  morbid  humours  which  belong  to  a 
bygone  pathology,  not  deposit  of  urate  of  soda  in  the  tissues." 

I  venture  to  hope  that,  in  respect  of  gout,  the  pathology  of  the  future,  as  elucidated 
by  that  which  most  especially  concerns  us  as  practical  physicians — the  clinical  side 
of  it — will  help  to  enlarge  our  conceptions  of  the  disease  as  a  whole,  and  to  bring 
into  closer  correlation  the  many  and  varied  aspects  of  it. 


CHAPTER  X. 

GOUT  IN  RELATION  TO  VARIOUS  NEUROSES. 

The  occurrence  of  gouty  habit  in  the  ancestors  of  persons  exhibit- 
ing many  neurotic  disorders  has  not  escaped  the  attention  of  the 
careful  clinical  observer.  The  same  cannot  be  affirmed  with  respect 
to  the  scrofulous  habit.  It  is  of  high  importance  to  recognize  the 
fact  of  special  predisposition  on  the  part  of  gouty  inheritors  to 
instability  of  the  nervous  system. 

To  the  varied  manifestations  of  the  neuroses,  and  of  their  pecu- 
liar tendency  to  alternate  in  successive  generations,  I  have  already 
referred.  Thus,  we  meet  occasionally  with  forms  of  insanity,  with 
epilepsy,  asthma,  angina  pectoris,  and  cardiac  neuroses  (vascular), 
headache,  hemicrania,  neuralgia,  vertigo,  and  the  whole  class  of 
disorders  included  under  the  terms  hypochondriasis  and  hysteria 
(neuromimesis).  It  is  certain  that  in  the  families  of  many 
subjects  of  these  disorders  a  distinct  history  of  antecedent  arthritic 
conditions  may  be  obtained,  and  if  such  be  found,  it  is  possible 
that  a  clue  to  more  efficient  treatment  may  be  gained  thereby. 
The  fact  is  of  supreme  importance  in  relation  to  the  part  played 
by  the  nervous  system  in  gouty  manifestations  generally.1 

I  have,  perhaps,  already  sufficiently  insisted  on  this  part  of  the 
pathogeny  of  gout,  and  directed  attention  to  the  peculiar  instability 
of  the  nervous  system  in  the  gouty.  I  shall  now  briefly  treat  of 
the  various  neurotic  ailments  just  mentioned,  and  endeavour  to 
trace  the  various  indications  of  arthritism  presented  by  them. 
They  are  usually  discussed  by  authors  under  the  head  of  irregular 
gout. 

Gout  in  Relation  to  Insanity. — Mania  has  been  met  with  on  the 
cessation  of  paroxysmal  gout,  and  has  yielded  on  the  supervention 
of  it. 

1  In  Dr.  Syers'  500  cases  of  acute  rheumatism,  already  referred  to,  he  found  ante- 
cedent neurotic  history  in  16  per  cent,  of  them.     Lancet,  June  30,  1888. 


214  GOUT   IN    RELATION    TO    VARIOUS    NEUROSES. 

Dr.  Rayner,1  of  Hanwell,  supports  the  views  of  Berthier,  which  go 
to  prove  that  every  form  of  insanity  may  be  produced  by  gout.  He 
has  recorded  an  instance  in  proof  of  the  first  allegation,  and  Garrod 
mentions  others.  In  atonic  articular  gout  with  general  debility, 
he  noted  two  cases  where  hallucinations  of  sight  and  hearing,  pro- 
ducing great  suspicion  and  distrust,  occurred,  the  patients  reco- 
vering after  an  attack  of  gout.  In  cases  of  imperfectly  developed 
gout,  he  mentions  cases  where  there  were  delusions,  at  first  exalted, 
then  becoming  melancholy,  an  attack  of  frank  gout  causing  the 
disappearance  of  these  symptoms.  In  saturnine  gout  he  met 
with  proptosis  and  an  extreme  darkness  of  complexion,  especially 
in  melancholic  cases,  both  symptoms  diminishing  as  the  health 
improved.      He  concluded  that — 

1.  Protracted  gouty  toxaemia,  when  not  very  intense,  usually 
results  in  sensory  hallucinations,  or  melancholia. 

2.  Sudden  and  intense  toxaemia  results  in  mania  or  epilepsy. 

3.  Intense  and  protracted  toxaemia  usually  results  in  general 
paralysis. 

4.  If  there  is  a  tendency  to  vascular  degeneration  from 
plumbism,  alcoholism,  &c,  varying  degrees  of  dementia  are  pro- 
duced. 

In  the  discussion  on  this  paper,  Dr.  Savage  declared  himself 
in  agreement  with  Dr.  Rayner.  Sir  J.  Crichton-Browne  was  of 
opinion  that  insanity  only  occurred  in  gouty  patients  who  were 
hereditarily  predisposed  to  it,  or  to  epilepsy.  He  believed  that 
many  cases  of  melancholia  attonita  in  young  girls  with  feeble 
circulation  were  connected  with  inherited  gout. 

Gout  in  Relation  to  Melancholia. —  Gout  may  alternate  with 
attacks  of  melancholia,  and  the  latter  may  replace  an  attack  of 
gout.  Excess  of  uric  acid  in  the  blood  is  apparently  the  deter- 
mining factor.  Dr.  Haig  suggests  that  there  may  possibly  be 
found  every  gradation  of  psychical  abnormality,  from  mere  de- 
pression of  spirits  and  bad  temper  up  to  melancholia  and  suicidal, 
or  other,  forms  of  mania,  produced  by  uric  acid  retention,  and  he 
remarks  that  the  diet  which  is  useful  in  headache  and  epilepsy — 
largely  vegetarian — is  of  use  in  some  forms  of  insanity.2 

In  such  cases,  as  Dr.  Haig  points  out,  and  as  Dr.  Broadbent 
has  shown,  there  is  often  present  high  arterial  tension,  which  is 
known  to  vary  with  the  amount  of  uric  acid  in  the  blood,  and 
also  to  be  amenable  to  restricted  diet  without  animal  food. 

1  Trans.  Internal;.  Med.  Congress,  vol.  iii.  p.  640,  1S81. 

2  Practitioner,  November  1S88,   Mental  Depression  and  the  Excretion  of   Uric 
Acid,  p.  342. 


MELANCHOLIA.       EPILEPSY.  2 1 5 

Dr.  Savage  has  directed  attention  to  cases  of  this  kind,  and 
recorded  instances  in  which  attacks  of  gout  were  coincident  with 
complete  relief  to  mental  depression  and  mania.1 

I  have  knowledge  of  cases  of  grave  suicidal  tendency,  and 
morbid  apprehensions  of  giving  way  to  it,  having  at  once  yielded 
either  to  anti-gouty  medication  or  to  outburst  of  acute  gout.  It 
is  obviously  very  important  to  be  aware  of  such  facts,  both  for 
diagnostic  and  therapeutic  purposes. 

Gout  in  Relation  to  Epilepsy. — Certain  cases  of  epilepsy  appear 
to  be  connected  with  the  gouty  habit.  Instances  have  been 
recorded  in  which  the  attacks  ceased  on  the  supervention  of 
regular  gout,  and  Garrod  found  a  large  amount  of  uric  acid  in 
the  blood  in  one  such  case.  From  this  category  are,  of  course, 
excluded  all  cases  of  convulsions  which  occur  in  the  subjects  of 
gouty  cachexia,  where  with  granular  kidneys  the  fits  probably 
depend  on  uraemia.  The  most  noteworthy  cases  are  those  met 
with  in  younger  patients  of  neurotic  inheritance,  who  may  pre- 
sent modifications  of  that  directly  inherited. 

Attention  has  been  directed  to  this  class  by  Dr.  Haig,  who 
presents  some  forcible  arguments  in  favour  of  the  view  that  cer- 
tain epileptics  owe  their  malady  to  the  effects  of  uric  acid  irrita- 
tion as  a  direct  excitant.  We  may,  therefore,  take  a  neuro-humoral 
view  of  such  cases,  for  the  existence  of  epilepsy  as  a  product 
of  urichaBmia  alone  cannot,  of  course,  be  admitted.  There  must,  I 
hold,  always  be  the  "  nervous  "  factor  in  any  case,  consisting  of  an 
inherited  proclivity  to  instability  in  certain  nerve-centres.  With 
this,  it  is  not  difficult  to  understand  that  accumulation  of  uric 
acid  within  the  body  may  sometimes  determine  and  precipitate 
an  explosive  paroxysm. 

Gout,  Epilepsy,  Injury  to  Back. 

B.  J.,  get.  forty-six,  formerly  in  army,  and  in  the  Crimean  war,  was  admitted  under 
my  care  in  Mark  Ward  in  July  1882.  A  man  of  large  frame,  slightly  anasmic. 
First  attack  of  gout  at  twenty-eight  in  feet.  Six  months  ago  fell  down-stairs  and 
hurt  his  back.  Three  months  ago  had  a  fit,  was  unconscious  and  bit  his  tongue. 
Some  doubt  as  to  an  aura.  No  history  of  syphilis.  No  gout  since  he  was  thirty- 
three.  The  heart-sounds  were  clear  but  feeble.  Tarso-metatarsal  joints  enlarged. 
Optic  discs  natural.  On  August  4th  an  attack  of  gout,  left  great  toe-joint.  The 
urine  was  void  of  albumen  and  glucose.  Several  fits  of  epilepsy  occurred  at  intervals 
while  in  hospital. 

Epilepsy  {?  Uraemic  Eclampsia)  in  a  Gouty  Man. 

R.  P.,  set.  fifty-two,  son  of  very  gouty  father,  and  formerly  intemperate,  came 
under  my  care  in  January  1876.     First  had  gout  at  age  of  thirty  in  great  toe  and 

1  Insanitv  and  Allied  Neuroses.     Lond.,  18S8. 


2l6  GOUT    IN    EELATION    TO    VARIOUS   NEUROSES. 

knee-joints.  None  for  last  two  years.  Been  a  total  abstainer  for  nearly  three  years, 
but  broke  his  pledge  last  Christmas.  An  attack  of  gout  recently.  Has  had  four  epi- 
leptic fits  in  last  three  years,  occurring  half  an  hour  after  going  to  bed.  Worry  or 
overwork  appears  to  determine  these  attacks.  The  urine  was  1005,  and  free  from 
albumen,  and  the  patient  had  cramps.  His  kidneys  were  probably  in  process  of 
contraction. 

Van  Swieten  records  the  following  : — "  I  had  the  care  of  a  man  who  was  seized  at 
first  with  severe  pains  in  his  lower  belly,  delirium,  and  strong  tremor  over  his 
whole  body.  He  afterwards  became  epileptic,  and  having  suffered,  in  the  space  of  a 
month,  three  severe  fits  of  that  distemper,  a  sharp  fit  of  the  gout  at  last  seized  upon 
his  great-toe,  and  from  the  time  he  became  gouty  he  remained  entirely  free  from  the 
epilepsy,  and  was  always  sure  of  having  a  return  of  the  gout  regularly  twice  a  year." 
He  quotes  Hippocrates  for  the  opinion  that  "  capital  disorders,  attended  with  an 
extreme  degree  of  violence,  are  in  a  critical  manner  cured  by  the  sciatica." — Com- 
mentaries on  Bocrhaave's  Aphorisms. 

Amongst  occasional  predisposing  conditions  of  epilepsy,  Dr. 
Copland  mentioned  the  gouty  diathesis.1  The  evidence  adduced 
by  Dr.  Haig  in  favour  of  this  view  is  that  fluctuations  occur  in 
uric  acid  excretion  in  some  cases  of  epilepsy,  just  as  in  cases  of 
gout  and  uric  acid  headache.  The  value  of  vegetarian  diet  in  this 
disease,  and  the  benefit  derived  from  alkalies  given  with  bromides 
in  many  of  the  cases,  are  also  adduced  in  favour  of  this  view. 

In  many  cases  there  is  family  history  of  gout  or  gouty  ail- 
ments. Iron,  which  is  harmful  in  this  class  of  patients,  and  leads 
to  retention  of  uric  acid,  is  commonly  injurious  in  epilepsy. 

Chorea. — No  evidence  of  any  force  has  been  adduced  to  prove 
any  direct  connection  between  gout  and  chorea.  This  is  the  more 
noteworthy  because  the  relationship  between  rheumatic  habit  of 
body  and  chorea  has  been,  certainly  to  my  mind,  very  conclu- 
sively proved  for  the  majority  of  all  cases.  The  seat  of  chorea  is 
without  doubt  in  the  nervous  motor  centres,  and  rheumatism  is  a 
disease  especially  affecting  motor  structures,  in  particular  the  heart 
and  joints.  I  regard  chorea  as  a  motorial  neurosis,  and  believe 
that  a  common  kindred  vulnerability,  or  susceptibility,  in  the  great 
motor  centres  may  predispose,  under  certain  excitants,  to  one  or 
other,  or  both,  of  the  disturbances  known  as  chorea  and  rheumatism.2 

Amongst  my  notes  I  find  the  case  of — 

K.  R.,  set.  seventeen,  a  machinist,  who  came  suffering  from  a  second  attack  of 
chorea.  The  first  attack  occurred  two  years  previously,  and  lasted  for  three  months. 
She  was  one  of  six  children.  The  eldest  had  had  "rheumatism,"  but  never  been 
bedridden,  and  one  had  "rheumatism"  in  an  ankle.  I  saw  her  father,  aged  fifty- 
seven,  and  he  gave  a  history  of  an  attack  of  gout  at  the  age  of  forty-one,  which 
affected  his  toes,  ankles,  and  knees.  He  was  a  free-drinker  of  "  four  ale,"  porter, 
and  spirits. 

1  Dictionary  of  Medicine.     London,  1858. 

2  Vide  An  Address  on  Chorea,  Brit.  Med.  Journ.,  January  3,  1885,  in  which  I 
have  urged  this  view. 


ASTHMA.  2  I  7 

In  the  following  case,  for  which  I  am  indebted  to  my  colleague 
Dr.  Gee,  hemichorea  occurred  on  the  right  side,  and  was  probably 
due  to  hgemorrhage  from  arterial  embolism  in  the  left  internal 
capsule.      I  was  present  at  the  autopsy. 

Gout — Riijld  Hemichorea — Death, 

J.  A.,  set.  fifty-four,  painter  all  his  life,  was  admitted  to  Luke  Ward,  November 
7,  18S1.     Twice  married,  five  children. 

No  symptoms  of  lead-poisoning  ;  no  blue  line  ;  no  colic  or  paralysis.  Gout  seven 
years  ago.  Drank  beer  freely  always;  not  much  spirit.  No  syphilis.  Bronchitis,  occa- 
sionally, five  years,  last  time  two  years  ago.  Went  to  work  on  November  2  apparently 
quite  well.  Right  hand  was  noticed  to  tremble  a  good  deal,  and  this  soon  extended  to 
right  leg  (choreic  movements  ceasing  during  sleep),  since  when  movements  have  been 
almost  constant.  Four  months  ago  right  hand  was  not  very  steady.  No  other 
affection  of  muscles  of  face  or  trunk.  Sensibility  perfect.  Right  hand  dusky  and 
congested.  Special  senses  natural.  Pulse  8o,  regular.  Patellar  tendon-reflex 
natural.  P.S.  in  chest,  wheezy  respiration,  prolonged  expiration.  Heart-sounds 
natural,  feeble  ;  dulness  abolished.     Liver  depressed.      Pulmonary  emphysema. 

November  io. — Became  very  restless  in  afternoon  yesterday,  and  delirious  in 
evening  ;  occasionally  very  violent  paroxysms.  Leg  more  restless.  At  io  P.M.  re- 
moved to  Casualty  Ward,  shouting.  Got  i\  gr.  morphia  subcutaneously.  Takes 
food  well. 

November  II. — Restless,  dyspnoea  after  paroxysms.  Choral  f)ss.  21s  horis.  On 
ophthalmoscopic  examination,  discs  natural. 

November  l6.— Quieter  last  few  days.  Right  arm  been  getting  sore,  brawny, 
fluctuation  ;  abscess  opened. 

November  19. — Excited  by  visitors  yesterday.  Passed  urine  under  him  in  bed. 
Chloral  and  bromides  given. 

November  21. — Temperature  rose  to  104.6°.  No  rigors.  Movements  continue. 
Tongue  dry  and  brown.  No  fresh  P.S.  in  lungs.  Urine  no  albumen.  Very  irascible  ; 
delirious.  Temperature  101. 2°  on  admission  (on  10th).  Nightly  rises  to  100°,  100.6°, 
101. 2°,  and  on  20th  104.6°.     21st  same.      100.6°  night  of  20th.     Last  night  103.8°. 

Died  on  23rd  (morning  I  A.M.). 

Post-mortem  examination  (November  24). — Lungs  emphysematous.  Heart  rather 
large,  flabby  ;  a  calcareo-atheromatous  ring  over  middle  aortic  cusp,  sharp,  and 
likely  to  cause  onward  murmur,  and  shedding  of  fibrinous  fragments.  Kidneys 
weighed  together,  just  under  eleven  ounces.  Commencing  cirrhosis.  No  uratic 
streaks.  Liver  and  spleen  natural.  Brain,  a  speck  of  haemorrhage  was  found  in 
the  internal  capsule  on  the  left  side,  lying  near  the  optic  thalamus,  but  separated 
completely  from  it. 

Gout  in  Relation  to  Asthma. — The  relation  of  the  gouty  habit 
of  body  to  asthma  is  marked  and  important.  Certain  cases  of 
asthma  appear  to  be  plainly  connected  with  gouty  inheritance  and 
constitution.  Family  and  personal  history  often  illustrate  this 
connection.  Paroxysmal  tendency  pertains  to  the  gouty  habit, 
doubtless  in  dependence  on  the  inherent  neurosal  features  of  it. 
The  subsidence  of  regular  gouty  attacks  is  followed  sometimes  by 
an  asthmatic  paroxysm,  and  the  latter  yields  to  onset  of  frank 
gout  in  some  part. 

The  skin-affections  common  to  the  gouty  may  alternate  with 


2l8  GOUT    IN    RELATION   TO    VARIOUS   NEUROSES. 

attacks  of  asthma.  The  paroxysms  may  come  on  in  the  early 
morning  hours,  exactly  as  in  the  case  of  attacks  of  gouty  arthritis. 
Bronchitis  is  common  in  the  gouty,  but  may  be  void  of  asthmatic 
complication.  In  some  cases  both  are  well-marked.  Amongst  the 
varied  metamorphoses  of  neurotic  states,  asthma  takes  its  place 
in  the  list,  and  is  found  interchanging  with  epilepsy,  neuralgia, 
chorea,  migraine,  and  insanity.1  It  may  be  directly  hereditary,  or 
may  appear  as  a  transformation  of  another  inherited  neurosis.  A 
gouty  habit  may  be  a  basis  for  all  these  conditions. 

Regarding  asthma  as  a  paroxysmal  dyspnoea  due  to  altered 
innervation  of  the  bronchial  tubes,  its  etiology  in  each  case  has 
to  be  specially  sought.  Any  pulmonary  lesion  by  itself  is  insuffi- 
cient to  explain  its  occurrence.  The  relation  of  gout  to  this 
condition  appears  to  depend  not  merely  on  the  altered  blood-state 
(humoral  cause),  but  equally  on  the  neurosal  condition  associated 
with  this.  The  asthma  of  the  gouty  is,  therefore,  neuro-humoral, 
and  due  either  to  central  or  local  irritation.  Cases  owning  this 
dependence  may  arise  at  various  ages.  In  the  young,  where  no 
obvious  gouty  symptoms  appear,  the  neurosal  element  is  alone 
manifested  for  the  most  part.  In  persons  in  the  fourth  decade, 
overt  gouty  symptoms  may  appear,  but  arthritic  inheritance 
may  be  equally  strong  in  instances  of  either.  Both  sexes  may 
suffer,  but  in  women  we  are  naturally  less  likely  to  find  clinical 
evidence  of  the  gouty  taint  than  in  men.  It  would  appear,  indeed, 
to  be  rather  common  to  find  the  neurosal  evolution  of  gouty 
inheritance  transmitted  to  the  female  side  with  greater  energy. 

In  elderly  persons,  thus  affected,  attention  must  always  be  paid 
to  the  efficiency  of  the  kidneys,  granular  condition  being  so  com- 
monly associated  with  gout. 

Uraemic  asthma  may  be  mistaken  for  the  simpler  and  less  grave 
form  of  alternating  gouty  asthma,  but  not  seldom  in  the  latter 
category  may  the  urine  afford  evidence  of  progressing  damage  in 
the  kidneys,  some  degree  of  albuminuria  being  present,  and  its 
amount  possibly  increased  under  the  congestive  influences  of 
bronchitis,  emphysema  of  the  lungs,  and  distension  of  the  right 
side  of  the  heart. 

A  clinical  distinction  may  sometimes  be  made  between  urasmic 
and  bronchitic  or  other  forms  of  asthma.  In  the  former  there  may 
be  no  superadded  respiratory  sounds,  the  air-entry  being  clear,  and 
even  exaggerated.  This  fact  has  led  to  the  belief  that  the  obstruc- 
tion  in  urasmic  asthma  is  due  rather  to  spasm  of  the  pulmonary 

1  "  Should  gout  seize  upon  the  lungs,  there  succeeds  a  violent  asthma  that  threatens 
suffocation,  which  is  preceded  by  a  dry,  uneasy  cough." — van  Swieten,  op.  cit. 


ANGINA    PECTORIS.  2IQ. 

arterioles  than  to  that  of  the  finer  bronchi,  the  cause  being  pos- 
sibly some  urinary  poison  acting  on  the  blood-vessels.1 

Hay-Asthma— Summer  Catarrh. — Noel  Gueneau  de  Mussy  was 
of  opinion  that  many  cases  of  hay-fever  were  especially  frequent 
in  members  of  gouty  families,  and  he  regarded  the  changes  in  the 
mucous  membrane  of  the  nasal  passages  as  akin  to  the  eruptions 
which  vex  the  skin  of  gouty  subjects."  He  recorded  ten  cases  in 
illustration  of  this.      I  have  sometimes  noted  the  connection. 


Gout  in  Relation  to  Angina  Pectoris  and  Cardio- 
vascular Neuroses. 

A  connection  between  gout  and  angina  pectoris  has  often  been 
affirmed  by  systematic  writers,  but  not  many  cases  in  support 
of  it  are  on  record.  Two  prominent  features  of  the  neuroses  per- 
tain to  attacks  of  angina  pectoris,  viz.,  paroxysmal  tendency  and 
extreme  painfulness. 

Peter  Mere  Latham  was  evidently  sceptical  of  the  direct  con- 
nection between  gout  and  true  angina,  and  had  no  experience  of 
alternation  of  one  with  the  other.  He  remarked  that  he  could 
conceive  this  to  have  happened  in  cases  "  where  the  angina  has 
been  an  affection  truly  vital,  and  the  heart  has  suffered  pain  and 
spasm,  though  perfectly  sound  of  structure.  That  such  an  angina 
should  germinate  from  the  same  root  as  gout  is  not  unlikely."3 

True  angina  pectoris  with  a  fatal  issue  is,  fortunately,  a  rare 
disease.  It  affects  chiefly  the  male  sex  and  persons  in  the  upper 
ranks  of  life  about  the  eighth  climacteric  period. 

It  may  be  affirmed  that  the  grave  forms  of  angina  pectoris  are 
hardly  recognized  apart  from  organic  disease  of  the  heart.  Angi- 
nal attacks,  sometimes  termed  pseudo-angina,  may  occur  without 
overt  cardiac  disease,  and  be  met  with  in  young  persons.  Such 
angina  as  is  clinically  referable  to  gouty  influence  may  be  put  into 
two  categories  :  first  and  chiefly,  pseudo- angina,  a  form  occurring 
where  the  heart  is  presumably  sound,  in  immediate  connection 
with  a  recent  or  imminent  articular  attack ;  and,  secondly,  the 
severe  form  which  is  associated  with  arteritis,  degenerative  change 
in  the  cardiac  walls  and  sclerosing  valvular  lesions,  of  which  the 
commonest  type  is  aortic,  and  especially  that  permitting  of  reflux. 

Imprudent  exposure  during  recovery  from  an  attack  of  gout  in 

1  This  point  was  originated  and  well  discussed  by  Dr.  William  Carter,  of  Liver- 
pool, in  the  Bradshawe  Lecture  (Roy.  Coll.  of  Physicians),  1888.  Lancet,  August 
25.  P-  359,  1888.  2  Gaz.  Held.,  ix.  9,  1872. 

6  On  the  Diseases  of  the  Heart,  vol.  ii.,  1846,  p.  419. 


2  20  GOUT   IN    RELATION  TO    VARIOUS    NEUROSES. 

the  feet  has  been  known  to  excite  pseudo-angina,  as  in  a  case 
related  by  Garrod,  where  several  seizures  occurred,  the  foot  again 
becoming  gouty.1  There  were  no  signs  of  cardiac  disease  in  the 
patient.  It  appears  probable  that  this  was  an  instance  of  meta- 
stasis, akin  to  other  forms  of  visceral  gout,  which  may  occur  under 
similar  circumstances. 

Professor  Gairdner,  reviewing  the  evidences  of  connection  be- 
tween gout  and  angina,  believes  that  it  may  be  inferred  that  the, 
so-called,  metastasis  of  gout  to  the  heart  is  the  result  of  gradual 
degenerative  changes  operating  more  or  less  throughout  the 
organism,  which,  if  not  so  distinctly  related,  as  has  sometimes 
been  supposed,  to  the  gouty  paroxysm  in  its  ordinary  form,  are  at 
all  events  closely  associated  with  the  causes  of  gout,  and,  therefore, 
form  part  of  its  history  as  a  disease  of  the  constitution.2 

Lecorche  remarks,  "  Pour  nous  la  maladie  d'Heberden,  chez 
les  goutteux,  est  toujours  due  a  une  arterite  goutteuse  des  coro- 
naires." 

It  has  already  been  shown  in  the  chapter  on  morbid  anatomy 
that  the  heart  and  arterial  system  suffer  severely  in  the  course  of 
chronic  gout.  The  morbid  changes  are  precisely  those  which, 
when  induced  by  other  cachectic  states,  lead  sometimes  to  asso- 
ciated angina ;  hence,  it  is  impossible  to  resist  the  conclusion  that 
the  gross  degenerations,  however  set  up,  are  directly  connected 
with  the  phenomena  of  the  anginal  attacks. 

Direct  evidence  is  not  wanting  to  prove  in  some  instances  that 
the  sclerosing  changes  in  the  aorta  and  coronary  arteries  directly 
involve  and  compress  branches  of  the  cardiac  nervous  plexus. 
The  aorta  and  coronary  arteries  may  be  sufficiently  diseased  to 
induce  degeneration  of  the  cardiac  walls  without  any  very  marked 
physical  signs.  In  such  cases,  angina  may  supervene  and  the 
heart  be  deemed  fairly  sound,  unless  proof  to  the  contrary  is  fur- 
nished by  an  autopsy.  In  this  way  may  possibly  be  explained 
some  of  the  cases  of  fatal  angina  in  which  the  heart  has  been 
believed  to  be  healthy. 

It  is,  perhaps,  more  difficult  to  explain  why  angina  should  not 
be  always  present  where  advanced  arterial  atheroma  has  led  to 
softening  and  dilatation  of  the  cardiac  walls,  since  it  is  certain 
that  many  cases  of  this  kind  occur  and  end  fatally  without  a 
symptom  of  angina.  I  would  suggest  that,  in  such  instances, 
there  is  an  absence  of  the  necessary  neurosal  element  to  deter- 
mine the  paroxysms. 

1  Op.  cit.,  p.  440. 
3  Art.  "  Angina  Pectoris,"  Reynolds'  Syst.  of  Med.,  vol.  iv.  p.  547. 


ANGINA    PECTORIS.  22  1 

The  relationship  of  the  gouty  habit  to  angina  may  be  thus 
expressed : — 

(i.)  Pseudo-angina-pectoris  may  occur  as  an  attendant  on 
chronic  gout.  This  is  certainly  the  more  common  form  in  which 
attacks  of  cardiac  pain  occur  in  the  gouty.  Its  characters  are, 
constrictive  pain  with  paroxysms  of  palpitation,  faintness,  giddi- 
ness, and  panting  respiration.  There  is  commonly  gastric  dis- 
turbance, indigestion,  and  flatulency.  The  patient  may  be  under 
fifty  years  of  age,  at  a  time  of  life  when  true  (grave)  angina  is 
uncommon,  and  is  usually  a  male  subject. 

(2.)  True  angina  pectoris  may  supervene  in  cases  of  chronic 
gout  or  of  gouty  cachexia,  in  which  wide-spread  arterial  degenera- 
tion, aortic  atheroma,  and  softening  of  the  cardiac  walls  have 
occurred  along  with  other  signs  of  textural  decay.  Here,  the 
gouty  state  is  the  factor  which  prepares  the  way  for  the  onset  of 
angina ;  but  similar  degenerations  may  be  induced  by  other  than 
gouty  influences. 

In  this  form  the  patient  is  usually  over  fifty  years  of  age.  The 
pain  is  tearing  and  violently  constrictive,  radiating  to  the  back 
and  often  down  the  arms,  but  especially  the  left  one,  as  far  as  the 
inner  sides  of  the  elbow.  There  is  no  sense  of  dyspnoea.  The 
pulse  is  small,  tense,  irregular,  and  may  be  infrequent.  The 
patient  experiences  a  sense  of  imminent  dissolution.  There  may 
be  gastric  flatulency.  After  the  paroxysm  a  large  flow  of  urine 
may  occur. 

It  may  be  noted  that  the  subjects  of  angina  pectoris  are  not 
infrequently  men  of  great  ability  and  mental  activity,  just  the 
class  so  often  affected  with  gout. 

Cases  of  angina  pectoris  have  been  described  as  diaphragmatic 
gout. 

The  heart  is  not  found  to  present  indications  of  organic 
disease  in  instances  of  pure  cardialgia  or  pseudo-angina,  and  no 
marked  change  may  be  detectible  in  the  arteries.  The  patients 
are,  as  a  rule,  too  young  to  be  thus  affected,  and  are  far  from 
the  stage  of  gouty  cachexia.  The  attacks  may  be  severe  and 
well-pronounced,  and  may  occur  at  long  intervals.  They  are 
frequent  in  the  night.  Sometimes,  patients  present  these  symp- 
toms without  having  experienced  any  regular  fits  of  gout ;  but 
a  marked  family  history  of  the  disease  is  usually  to  be  elicited 
in  such  a  case.  We  may,  therefore,  agree  with  Trousseau,  who 
regarded  such  paroxysms  as  "  manifestations  of  the  gouty  dia- 
thesis." 

The  relationship  of  gout  to   anginal  tendency  cannot  be  dis- 


222  GOUT    IN    RELATION  TO    VARIOUS    NEUROSES. 

missed  without  reference  to  the  special  neurosal  quality  attach- 
ing to  each.  In  each  there  may  be  gross  changes,  or  conditions 
favourable  for  attack ;  but  the  special  determinant  and  pre- 
dominating features  come  from  the  nervous  side,  whence  the 
explosive  paroxysm  and  the  painfullness.  It  is  impossible  not  to 
take  note  of  an  underlying  specific  state  of  the  nerve-centres  in 
the  two  cases,  instability  and  proneness  to  discharge  along  cer- 
tain nerve-tracts  probably  representing  the  perverse  functional 
condition. 

We  may,  thus,  discover  a  radical  (neurotic)  relationship  between 
the  gouty  habit  and  the  occasional  tendency  to  attacks,  not  only 
of  angina  pectoris,  but  of  other  painful  nerve-states. 

The  influence  of  emotion  as  a  determinant,  and  the  tendency 
to  paroxysms  in  early  hours  of  the  morning  after  the  first  sleep,1 
pertain  to  other  spasmodic  neuroses. 

Graves'  Disease,  or  exophthalmic  goitre,  has  been  noted  in 
persons  descended  from  gouty  parents.  I  have,  so  far  as  I 
know,  only  met  with  one  instance  of  this  kind,  in  the  case 
of  a  lady  who  was  "  nervous "  and  hysterical.  Towards  the 
menopause  symptoms  of  Graves'  disease  came  on.  These  passed 
off  within  a  year,  and  much  benefit  was  derived  from  subalpine 
residence  in  Switzerland.  The  father  and  several  brothers  had 
distinct  gouty  indications. 

Tachycardia. — Cardiac  palpitation  is  recognized  as  occurring 
in  arthritically  disposed  persons.  Cases  of  chronic  rheumatic 
arthritis  in  its  rapidly  progressing  form  are  sometimes  character- 
ized by  tachycardia  almost  from  the  onset,  the  pulse  being  tense 
and  rising  to  ninety  or  higher.  I  have  met  with  one  or  two 
examples  in  women  where  the  pulse  remained  persistently  from 
150  to  200  per  minute;  but  I  have  never  seen  anything  like 
this  in  gout.2  No  signs  of  gross  cardiac  disease  are  detectible 
in  the  rheumatic  cases,  and  there  is  no  associated  pyrexia.  This 
functional  tachycardia  may  endure  through  quiet  progress  of  the 
arthritis.3 

According  to  Gerhardt,  there  are  two  forms  of  tachycardia,  (a) 
lasting  and  (b)  transitory.      Most  cases  of  the  nervous  form   he 

1  "Nonrmllos  adoritur  post  primum  somni  tempus  ;  quod  in  morbis  ex  distentions 
frequens  est." — Heberden. 

2  Dr.  Baillie  related  to  Dr.  Seudamore  a  case  in  which  palpitation  of  the  heart  was 
experienced  for  six  months  without  relief  from  medicine.  A  fit  of  gout  suddenly  and 
entirely  removed  it. 

3  Dr.  Spender,  of  Bath,  has  described  some  cases  of  this  nature.  Brit.  Med. 
Journal,  April  14,  1888,  p.  781 ;  and  Early  Symptoms  and  Early  Treatment  of  Osteo- 
Arthritis,  London,  1889.  p.  6. 


PULSE-TRACINGS. 


z-5 


attributes  to  paralysis  of  the  vagus ;   those  which  have  a  pulse- 
rate  of  200,  to  a  combined  stimulation  of  the  vagus  and  sym- 


Fig.  17.—  Sphygmogram  from  case  of  chronic  gout  with  tophi  and  psoriasis.  Urine,  1002  ; 
containing  trace  of  albumen.  Illustrating  increased  tension.  (Probably  inter- 
stitial nephritis.) 


Fig.  18. — Sphygmogram  from  case  of  J.  A.,  set.  42.     Heart  feeble.     No  murmurs. 


Fig.  19. — Under  the  finger  this  pulse  did  not  indicate  increased  tension.     A.  J.,  aet.  50. 


Fig.  20.— (a.)  Illustrating  irregular  pulse  in  gout.  The  largest  sweeps  of  the  lever  occurred 
during  the  respiratory  pause,  the  smallest  during  and  after  inspiration,  (b.)  Pulse 
regular  during  an  attack  of  gout  (?  aortic  reflux).  (From  Prof.  Burdon  Sanderson's 
book  on  Sphygmograph,  p.  77.) 

pathetic.      The    higher   forms    he   considers   entirely  due  to   the 
latter.1 


1  Volkmann's  Collection  of  Clinical  Lectures.      New  Sydenham  Society  Trans., 
1881. 


224  GOUT   IN   RELATION    TO    VARIOUS  NEUROSES. 

I  have  noted  one  instance  in  a  case  of  severe  gouty  glyco- 
suria in  a  man  aged  fifty-two,  during  recovery  from  an  acute 
attack  of  arthritis,  the  temperature  being  but  little  raised,  and 
the  pulse  over  I  30. 

Undue  pulsation  of  the  abdominal  aorta  and  of  other  large 
arteries  is  another  occasional  symptom  in  gouty  persons,  met  with 
in  both  sexes,  and  sometimes  associated  with  dyspepsia,  tympa- 
nites, oxaluria,  and  hypochondriasis.1  I  have  known  many  examples 
of  this  disorder  mistaken  for  aneurysm,  but  have  noted  no  changes 
of  any  importance  in  the  vessels  in  such  cases  as  have,  from  other 
causes,  afforded  an  autopsy.  An  attack  of  articular  gout  may 
entirely  remove  the  symptoms. 

Irregularity  and  "  true "  intermission  of  pulsation  have  long 
been  known  as  symptoms  of  the  gouty  habit.  Although  some- 
times causing  anxiety  to  the  patient,  they  are  void  of  serious 
import,  and  are  not  the  expression  of  organic  heart-disease. 
There  is  absence  of  cardiac  systole  as  well  as  of  dropped  radial 
beat. 

In  patients  of  advanced  age,  with  signs  of  arterial  decay,  there 
may  be  found  with  the  arhythmia  signs  of  valvular  disease  and 
fatty  change  in  the  heart-walls.  In  such  instances  there  may  be 
cardiac  systole  with  dropped  beat  at  the  radials — "  false  "  inter- 
mission. 


Gout  in  Relation  to  Headache  and  Hemicrania. 

It  is  probable  that  few  bodily  discomforts  originate  in  so  wide 
a  field  of  causation  as  do  the  many  varieties  of  headache.  Much 
discrimination  is  necessary  in  referring  any  form  of  it  to  its  exact 
source.  Persons  of  gouty  habit  may  certainly  suffer  from  head- 
aches which  are  independent  of  that  habit. 

The  descriptions  by  the  older  writers  of  the  cerebral  symp- 
toms of  gout  comprise  cases  of  headache  which  would  now  be 
recognized  as  due  to  uraemia,  rather  than  to  direct  influence 
of  uric  acid.  These  are  not  seldom  dependent  on  chronic  neph- 
ritis, the  result  of  gout.  The  history  of  previous  gouty  attacks 
appeared  formerly  to  justify  the  opinion  that  in  such  instances 
the  disorder  had  fallen  directly,  or  by  metastasis,  on  the  brain 
or  its  membranes. 

An  examination  of  the  urine,  heart,  arteries,  pulse,  and  retina 

1  First  described  by  Dr.  Matthew  Baillie  at  the  Royal  College  of  Physicians  in 
igi2.     Med.  Trans.,  published  by  the  College  in  181 3,  vol.  iv. 


HEADACHE.       HEMICRANIA.  225 

should  now  prevent  a  diagnostic  error  of  this  kind.  The  subject 
of  unequivocal  gouty,  or,  as  it  is  sometimes  termed,  uric  acid 
headache,  is  free  from  any  noteworthy  signs  of  degeneration  in 
any  of  the  structures  just  mentioned.  It  may  occur  within 
the  second  decade  of  life.  There  are  no  special  elective  sites 
for  it,  and  it  may  either  be  general,  or  localized  in  any  part  of 
the  head.  The  pain  varies  in  severity  from  that  of  the  uncom- 
fortable, or  "  muzzy,"  head  to  a  degree  of  great  intensity.  In 
severe  instances  the  surface  of  the  scalp  is  apt  to  be  hot  and 
tender,  so  that  even  pulling  of  a  single  hair  is  painful.  The  pain 
may  remit  during  an  attack  and  become  worse  after  an  interval, 
thus  presenting  a  paroxysmal  character,  which  has  sometimes 
led  to  the  belief  that  the  disorder  was  of  a  malarious  origin. 
The  headache,  after  lasting  for  some  days,  may  suddenly  yield 
to  an  attack  of  frank  articular  gout,  or  may  replace  such  an 
attack. 

Dr.  Lauder  Brunton  declares  his  inability  to  distinguish  a  gouty 
headache  from  that  of  plethora  or  indigestion,  and  would  suspect 
the  gouty  element  only  from  the  patient's  family  and  personal 
history.1 

Dr.  Haig  has  directed  attention  to  this  form  of  headache,  and 
has  shown  that  it  can  be  artificially  induced  at  any  time,  in  those 
subject  to  it,  by  indiscretions  of  diet,  or,  directly,  by  such  agents 
as  cause  increased  excretion  of  uric  acid.  The  increased  out-put 
of  uric  acid  and  the  headache  associated  with  this  are  believed  by 
Dr.  Haig  to  indicate  a  state  of  uricheemia,  since,  if  there  be  no 
surplusage  of  uric  acid  in  the  blood  or  system,  the  exhibition  of 
alkalies  (the  means  whereby  he  induces  headache  in  these  cases) 
fails  to  produce  either  the  increased  excretion  of  uric  acid  or  the 
headache. 

It  is  possible  in  practice  to  distinguish  between  the  gouty 
cephalalgia  of  most  authors  and  varieties  of  hemicrania  or  migraine. 
The  latter  may  occur  in  classical  form  with  teichopsia,  or  "  dazzles," 
(as  one  of  my  patients  termed  it),  be  strictly  one-sided,  and  ter- 
minate with  nausea  or  vomiting.  Whether  a  true  migraine  or  a 
severe  and  more  general  headache  shall  occur,  depends  probably 
on  personal  proclivities  and  peculiarities,  and,  not  least,  on  the 
degree  of  gouty  heredity.  I  believe  there  is  one  basic  source  for 
all  forms  in  those  who  are  gouty  for  the  time  being,  or  predisposed 
by  inheritance  or  otherwise  to  gout. 

Hemicrania  owns  other  causation  than  a  gouty  basis,  but  is 

1  St.  Earth.  Hosp.  Reports,  vol.  xix.  p.  340,  1883. 


2  26  GOUT  IN    RELATION"    TO    VARIOUS    NEUROSES. 

perhaps  more  common  in  those  of  gouty  inheritance.1  It  may 
occur  in  the  place  of  regular  gout,  but  more  often  appears  in 
those  who  never  develop  the  latter.  In  this  way  it  constitutes 
one  of  the  transformations  of  the  gouty  neurosis,  or  may  be 
regarded  as  a  form  of  incomplete  gout.  The  violent  headaches 
(gouty  cephalalgia)  which  least  correspond  to  hemicrania,  and 
which  are  apt  to  persist  for  some  days,  prevail  in  those  who  are 
already  the  subjects  of  frank  gout,  or  are  likely  soon  to  manifest 
it.  These  headaches  are  not  so  readily  induced  as  hemicrania, 
and  they  do  not  begin  early  in  life  and  recur  periodically  after 
the  manner  of  pure  megrim.  The  latter  is  much  the  more  fre- 
quent form  met  with,  but  many  persons  suffer  from  non-classical 
varieties  of  it.  The  most  regular  migraine  occurs  as  a  paroxysmal 
neurosis,  and  many  of  gouty  heritage  thus  suffer.  Imperfectly 
developed  attacks  may  also  affect  those  who  are  goutily  disposed, 
but  in  response  to  stronger  provocation  than  is  necessary  to  upset 
the  nervous  balance  in  the  victim  of  the  graver  form.  In  the 
latter  case  it  sometimes  happens  that  no  amount  of  care  and 
prudence  can  avert  occasional  paroxysms.  In  the  milder  forms 
such  measures  are  potent  to  avert  an  attack  for  long  periods,  as 
well  as  to  mitigate  the  intensity  of  it. 

As  in  other  neurotic  disorders,  there  is  always  a  tendency  for 
the  disease  to  grow  up  or  develop  to  a  certain  point  before  an 
outburst  occurs.  In  the  case  of  gouty  ailments  this  development 
is  commonly  attributed  to  uric  acid  retention,  and  this  view  may 
be  taken  as  generally  correct.  I  have  already  tried  to  show  that 
this  humoral  conception  is  not  all-explanatory,  and  that  the  ner- 
vous factors  in  each  case  must  be  equally  taken  note  of. 

The  provoking  causes  of  hemicrania  certainly  often  start  from 
the  nervous  side ;  thus,  exhaustion,  mental  or  bodily,  over-excite- 
ment, exposure  to  strong  light,  vivid  colours,  powerful  odours,  bad 
air,  noise,  anxiety,  fright,  &c,  are  no  less  determinants  of  an  attack 
than  are  single  or  repeated  indiscretions  in  diet.2 

I  agree  with  those  who  regard  hemicrania  as  a  paroxysmal 
nerve-storm  induced  by  one  or  more  of  the  causes  I  have  just 
enumerated,  and  I  am  fully  in  accord  with  the  views  set  forth  by 
Dr.  Edward  Liveing  in  his  masterly  treatise  on  the  whole  subject  of 
megrim.    The  characters  of  a  well-marked  attack  are  well-known. 

1  "Souvent  c'est  la  seule  expression  de  la  predisposition  here"ditaire  chez  des  sujets 
ne"s  de  parents  franchement  goutteux." — Trousseau. 

2  The  late  Professor  Rolleston  suggested  that  after  great  mental  emotion,  worry, 
or  brain-work,  the  worn-down  nervous  matter  came  to  act  as  a  poison  in  the  system, 
especially  affecting  the  sympathetic  centres,  leading  to  paralysis  of  them  and  a  nerve- 
storm. 


HEMICRANIA.  227 

The  onset  is  common  in  the  early  morning,  the  patient  waking 
with  a  sense  of  discomfort  in  the  head.  It  is  often  the  case  that 
there  has  been  previously  a  sense  of  hien-Stre,  the  head  having 
been  clear  and  all  bodily  functions  well-performed.  The  appetite 
may  have  been  especially  good.  The  attack  continues  during  the 
day,  probably  increasing  in  intensity,  with  sensation  of  chilliness, 
cold  feet,  and  general  malaise.  The  pain  is  of  throbbing  char- 
acter, shooting  into  the  eye-balls,  the  conjunctivas  are  injected,  and 
may  be  a  little  icteric  ;  pupils  rather  small.  Exertion  aggravates 
the  pain,  especially  the  effort  of  ascending  stairs,  which  excites 
throbbing  in  the  head.  There  may  be  slight  nausea,  or  the  appe- 
tite may  be  hardly  affected.  Teichopsia  may,  or  may  not,  be  pre- 
sent. The  instinct  is  for  absolute  rest  and  tranquillity  of  mind 
in  a  darkened  room,  with  warmth.  Recumbency  often  aggravates 
the  suffering.  Pressure  on  the  carotids,  while  maintained,  relieves 
the  pain.  The  pulse  is  infrequent,  small,  and  tense,  and  sub- 
jects of  these  headaches  commonly  have  abiding  high  arterial 
pressure.  This  is  increased  during  a  paroxysm.  In  my  expe- 
rience, the  distribution  of  the  headache  is  rather  general  than 
local,  with  sorer  points  in  some  parts,  such  as  are  animated  by 
the  great  occipital  or  supra-orbital  nerves.  There  is  frequent 
desire  to  micturate,  the  urine  being  pale  and  watery.  The  pain 
may  rage  till  the  evening,  sometimes  increasing  up  to  that  time, 
when  it  usually  subsides,  or  the  attack  may  last  over  the  second  day. 

Vomiting  is  occasionally  coincident  with  the  termination  of  the 
paroxysm.  The  motions  have  been  found  rather  paler  than  natu- 
ral at  the  time  of  the  attack. 

There  is  a  tendency  for  the  paroxysms  to  become  less  severe 
and  less  frequent  after  middle  life,  but  they  may  occur  up  to  the 
sixth  decade.  In  well-established  cases  they  may  come  on  every 
third  week,  and  it  is  seldom  that  an  entire  month  passes  without 
their  occurrence. 

There  are  more  or  less  attendant  prostration  and  depression,  and 
to  pursue  the  ordinary  duties  of  life  requires  a  strong  will  and  a 
high  moral  purpose.  Some  sufferers  are  fairly  overcome  for  the 
time  being,  and  unfit  to  face  their  avocations. 

The  description  just  given  relates  to  the  worst  form  of  megrim. 
There  are  many  degrees  of  intensity  in  the  attacks,  even  in  the 
same  patient,  but  in  its  most  attenuated  form  the  type  of  the 
disorder  is  always  recognizable. 

The  measures  which  best,  afford  relief  to  the  paroxysm  and 
prevent  its  recurrence  throw  light  on  the  nature  of  the  disorder, 
and  especially  when  it  is  manifestly  dependent  on  gouty  habit. 


2  28  GOUT    IN   RELATION   TO   VARIOUS    NEUROSES. 

Gout  in  Relation  to  Neuralgia. 

The  dependence  of  certain  forms  of  neuralgia  on  the  gouty- 
habit  is  well- ascertained.  Paroxysmal  and  periodic  as  in  other 
forms,  there  is  nothing  peculiar  about  the  painful  nerve-states  due 
to  a  gouty  condition  of  the  system.  The  diagnosis  is  founded  on 
the  ordinary  concomitants  of  the  basic  disorder.  Wherever  pain- 
fulness  is  a  feature  in  a  gouty  process,  there  is  commonly  a  severe 
degree  of  it,  and  it  is  ill-borne  by  the  sufferer.  Almost  any  nerve- 
trunk  may  be  affected,  and  it  is  characteristic,  perhaps,  of  gouty 
neuralgia  that  it  may  appear  in  sites  not  usually  involved  by 
other  forms  of  this  trouble.1 

Exposure  to  currents  of  cold  damp  air,  especially  to  north- 
east wind,  after  being  over-heated,  exhaustion  from  any  cause, 
bodily  or  mental,  loss  of  sleep,  undue  or  prolonged  excitement, 
are  the  most  frequent  determining  factors. 

Gouty  neuralgia  may  prove  very  rebellious  to  treatment,  even 
to  that  intelligently  directed  towards  the  cause  of  it.  This  is 
especially  the  case  in  persons  past  middle  life,  whose  textures 
indicate  signs  of  decay. 

The  attacks  may  alternate  with  overt  or  articular  gout,  on  the 
appearance  of  which  the  neuralgia  passes  off.  They  are  apt  to 
come  on  very  suddenly,  and  to  follow  quickly  on  errors  of  diet  or 
trivial  excitants. 

The  most  frequently  affected  nerves  are  the  supra-orbital  and 
occipital,  especially  the  great  occipital,  and  various  branches  of 
the  brachial  plexus.  Some  of  the  most  severe  forms  of  cervico- 
brachial  neuralgia  are  connected  with  gouty  taint.  Intercostal 
neuralgia  is  sometimes  thus  dependent.  In  the  lower  extremities 
the  great  ischiatic  nerve  is  most  commonly  involved,  giving  rise 
to  a  form  of  sciatica,  and  sometimes  the  anterior  crural  nerve  is 
the  seat  of  pain. 

In  some  cases  of,  so-called,  gouty  neuralgia  it  is  almost  certain 
that  a  more  accurate  diagnosis  would  be  that  of  neuritis.  I  sus- 
pect that  this  is  especially  the  case  in  many  examples  of  severe 
and  rebellious  sciatica.  In  such  instances  there  are  inflammatory 
changes  in  the  nerve-sheath,  leading  to  sclerosis. 

There  is  sometimes  difficulty  in  exactly  determining  whether 
the  "  pains  "  complained  of  are  actually  in  nerve-area,  or  are  due 
to  uratic  retention  and  localized  gouty  processes  in  lymph-spaces 
or   in   the    aponeuroses   of  muscles.      Such  pains    may    be  very 

1  "  Gout  affects  the  sensory  much  more  than  the  motor  elements  of  the  nervous 
system." — Paget,  Clin.  Led.,  2nd  edit.,  p.  382. 


NEURALGIA.  229 

severe  and  also  fugitive.  The  regular  paroxysmal  tendency  is 
wanting,  as  well  as  the  peculiar  benumbing  character  pertaining 
to  true  neuralgia  after  it  has  lasted  for  some  time.  The  fulgur- 
ant  pains  of  tabes  dorsalis  are  hardly  likely  to  be  mistaken  for 
ordinary  neuralgia  by  any  careful  observer. 

The  causes  that  commonly  excite  neuralgia  suffice  to  induce  it 
in  the  gouty.  The  determining  excitants  may  be  seemingly 
trifling,  and  such  as  would  fail  to  induce  the  disorder  if  the 
patient  were  not,  so  to  say,  in  an  explosive  condition,  that  is,  ripe 
for  some  gouty  manifestation. 

Sometimes,  neuralgia  is  the  exponent  of  gouty  heritage  in 
persons  who  have  as  yet  developed  no  overt  signs  of  ordinary 
gout,  thus  exhibiting  one  of  the  forms  of  transformation  already 
alluded  to.  This  is  perhaps  more  frequently  seen  in  women, 
and  there  may  be  found  a  low  state  of  general  health  with  such 
signs  as  betoken  an  incomplete,  or  asthenic,  gouty  state  of  body. 

In  more  plethoric  persons  there  will  usually  be  found  associated 
with  the  neuralgia  the  disturbed  digestion,  "muzzy"  head,  con- 
stipation, and  hepatic  fulness,  with  loaded  urine,  which  so  often 
precede  ordinary  gouty  attacks. 

It  is  not  without  interest  to  note  incidentally  that  neuralgia  is 
sometimes  associated  with  chronic  forms  of  saccharine  diabetes. 
I  have  already  recorded  some  cases  of  gouty  glycosuria  in  which 
severe  rachalgia,  apparently  neuralgic,  was  experienced,  but  I  have 
no  knowledge  of  instances  of  ordinary  neuralgia  in  this  class  of 
patients.      Bilateral  neuralgia  has  been  noted  in  diabetes. 

Herpes  Zoster,  and  other  varieties  of  herpes,  occur  in  the  gouty, 
and  the  subsequent  neuralgia,  especially  after  zona,  may  in  such 
persons  be  very  intense,  and  long  incoercible.  I  have  known 
zona  occur  in  this  form  together  with  equally  rebellious  gout  in 
a  great-toe  and  foot — a  very  formidable  combination — lasting  for 
many  weeks.1 

The  most  persistent  and  agonizing  varieties  of  neuralgia  which 
I  have  witnessed  in  the  gouty  have  been  those  involving  the  great 
occipital  nerve  2  and  the  cervico-brachial  plexus,  affecting  chiefly 
males  in  middle  life. 

As  noted  by  Paget,  a  gouty  neuralgia  may  often  be  recognized 
by  its  being  more  fitful  and  sudden  than  others,  and  more  quickly 
induced  by  errors  of  diet,  indigestion,  and  other  casual  circum- 

1  Mr.  W.  E.  Musson,  of  Clitheroe,  informs  me  that  his  attention  has  been  directed 
to  the  frequent  occurrence  of  herpes,  particularly  in  its  facial  forms,  in  gouty  subjects. 
Dr.  Symes  Thompson  has  also  noted  the  same. 

2  More  often  the  right  nerve  is  involved. 


230  GOUT   IN   RELATION    TO    VARIOUS   NEUROSES. 

stances ;  and  neuralgia  in  certain  parts  is  especially  significant  of 
gout,  as  in  the  heel,  external  ear,  tongue,  palate,  fingers,  and  breast. 
The  same  observer  also  noted  many  varieties  of  pain  and  dysgesthe- 
sia3  which  torment  the  gouty,  such  as  numbness,  sensations  of 
"  pins  and  needles"  in  the  toes  and  fingers,  and  "  dead"  fingers, 
which  become  cold  and  white,  and  subsequently  flush  and  grow  hot. 

The  following  case  of  genito-crural  herpes  was  recorded  in  the  British  Medical 
Journal  of  March  13,  18S0  : — 

A  patient,  about  sixty  years  of  age,  who  had  occasionally  suffered  from  gout,  expe- 
rienced left  lumbar  pain  extending  to  the  iliac  region,  and  causing  retraction  of  the 
left  testis.  This  came  on  after  having  got  wet  fishing,  and  while  recovering  from  an 
attack  of  gout.  The  pain  was  constant,  almost  unbearable  during  exacerbations, 
and  aggravated  by  movement.  There  was  frequent  micturition  of  clear  and  acid 
urine.  Bowels  regular.  Pulse  and  temperature  unaffected.  The  pain  continued  for 
two  days.  On  the  third  day  a  patch  of  herpes  appeared  on  the  upper  part  of  the  left 
thigh,  and  on  the  fourth  day  the  pain  passed  off.  The  patient's  father  suffered  from 
vesical  calculus,  and  had  it  crushed  at  the  age  of  seventy-three. 

Sudden  twitches  of  intense  pain,  lasting  only  a  few  seconds  or 
minutes,  or  for  some  hours,  are  apt  to  seize  goutily  disposed  per- 
sons, and  without  obvious  cause.  The  suffering  is  sometimes  very 
severe,  and  would  be  intolerable  if  long-continued.  The  legs, 
feet,  and  toes  are  the  commonest  sites  of  such  fugitive  pain. 
Sometimes,  the  ear  is  affected  with  sudden  pain,  which  lasts  only 
a  few  hours.  Graves  was  a  sufferer  from  this  on  one  occasion  for 
an  hour,  and  the  ailment  ceased  on  the  occurrence  of  gouty  pain 
in  his  fingers.  He  believed  that  sudden  congestions  of  the  parts 
so  affected  took  place.  It  is  probable  that  temporary  local  stasis 
of  acid  sodium  urate  is  the  cause. 

Dr.  Anstie  noted  six  situations  in  which  gouty  pains,  or  pains 
of  latent  gout,  are  apt  to  occur  simulating  neuralgia.1  He  did 
not  believe  in  an  intimate  causal  relation  between  gout  and  neu- 
ralgia. He  mentions  (1.)  pains  in  the  eye  ;  (2.)  more  indefinitely 
within  the  cranium;  (3.)  in  the  stomach,  simulating  gastralgia  ; 
(4.)  in  the  chest,  simulating  angina  pectoris;  (5.)  in  the  dorsum 
of  the  foot,  simulating  neuralgia  of  the  anterior  tibial  nerve  ;  (6.) 
in  a  somewhat  diffuse  manner  about  the  hip  and  back  of  the  thigh, 
simulating  sciatica.  If  the  pains  referred  to  are  not  neuralgic, 
they  can  only  be  due  to  localized  attacks  of  incomplete  gout,  which 
should  not  be  very  difficult  of  recognition. 

Gout  in  Relation  to  Vertigo. 

Amongst  the  symptoms  depending  on  irregular  gout  is  that  of 
giddiness   or   vertigo.      In  making  the  diagnosis,   care   must  be 

1  Neuralgia  and  its  Counterfeits,  1 87 1,  p.  270. 


VERTIGO.  23I 

taken  to  exclude  any  obvious  causes  not  connected  with  the  gouty 
habit  of  body.  Thus,  ocular,  aural  (labyrinthine),  and  epileptic 
vertigo  must  not  be  confounded  with  this  form. 

Sudden  attacks  of  gout  may  entirely  remove  tendency  to  ver- 
tigo of  long  duration.  Assumption  of  the  erect  posture  may  in- 
duce vertigo.  This  occurred  for  two  years  in  a  man  whose  case  is 
quoted  by  Trousseau  from  Boerhaave's  commentator  (van  Swieten). 
A  first  attack  of  gout  entirely  removed  the  tendency.  John 
Hunter  suffered  at  one  period  of  his  life  from  this  affection,  which 
lasted  ten  days,  during  which  time  he  was  compelled  to  keep 
prone. 

Vertigo  may  be  induced  in  the  goutily  disposed  by  irritating 
ingesta,  and  some  of  the  cases  of  so-called  gastric  vertigo  are,  no 
doubt,  of  this  class.  Murchison  relates  the  case  of  a  man  who  had 
long  suffered  from  gout,  and  who,  as  often  as  he  partook  of  a  cup 
of  tea  or  a  glass  of  champagne,  would  suffer  from  vertigo,  and  be 
compelled  to  hold  on  for  support.  There  was  no  loss  of  conscious- 
ness, and  this  attack  lasted  for  a  few  seconds  or  minutes.  The 
same  writer  relates  other  cases  in  which  vertigo  and  dimness  of 
vision  occurred  in  association  with  lithaemia,  but  not  with  gout.1 
Dr.  Moxon  met  with  a  case  in  which  a  gouty  man  suffered  so 
severely  from  vertigo,  that,  when  seized,  he  had  to  go  about  "  on 
all  fours." 

Mere  dimness  of  vision  may  constitute  a  minor  attack  of  this 
kind  of  vertigo.  This  occurs  in  the  gouty,  coming  on  suddenly 
while  reading  or  writing,  or  when  out  of  doors.  Trousseau 
records  an  instance  in  which  the  patient  felt  as  if  his  eyes  were 
covered  with  flakes  of  snow.  The  attacks  are  of  brief  duration, 
and  may  recur  several  times  for  a  day  or  two.  In  all  these  cases 
there  are  generally  associated  gouty  concomitants.2 

The  following  case  occurred  amongst  my  out-patients  in 
1882  : — 

J.  R.  S.,  set.  thirty-six,  a  marbler  of  book-edges,  came  complaining  of  tinglings 
and  "hot  surgings  of  blood"  in  the  fingers,  hands,  and  head.  This  was  apt  to  come 
on  a  quarter  of  an  hour  after  meals.  There  was  much  flatulence,  and,  occasionally, 
vertigo.     The  left  ventricle  of  the  heart  was  a  little  hypertrophied,  and  the  arteries 

1  Diseases  of  the  Liver,  p.  588,  2nd  edit. 

2  "  I  saw  a  man  who  for  two  years  was  afflicted  in  this  terrible  manner ;  to  wit,  as 
oft  as  he  remained  sitting  and  at  rest,  he  perceived  nothing  ;  but  the  moment  he  got 
up  to  stand  with  his  body  erect,  he  was  immediately  seized  with  a  giddiness,  and  fell 
down.  Many  things  he  tried  by  the  advice  of  the  ablest  physicians,  but  all  without 
success,  till  at  last  a  sudden  fit  of  the  gout,  which  he  never  had  experienced  before, 
cured  him  entirely  of  this  troublesome  vertigo." — Van  Swieten' s  Comment,  on  Boer- 
Jiaave's  Aphorisms,  Sect.  mcclxii. 


232  GOUT   IN    RELATION    TO    VAKIOUS   NEUROSES. 

somewhat  hard.  The  urine  was  of  sp.  gr.  1017,  void  of  albumen,  rich  in  indican. 
His  family  was,  he  alleged,  nervous  and  irritable.  The  father,  aged  sixty-nine, 
suffered  from  "  chalky  "  gout,  one  brother,  set.  twenty-five,  had  had  gout  in  a  great 
toe-joint,  and  a  sister,  set.  nine  years,  had  been  in  King's  College  Hospital  for  gout 
in  a  great  toe-joint. 

There  could  be  little  doubt  about  the  chain  of  events  in  this 
case. 

Gout  in  Relation  to  Hypochondriasis  and  Hysteria. 

The  dependence  of  hypochondriasis  on  a  gouty  habit  of  body 
is  most  plainly  recognized  in  cases  where  this  state  yields  to,  or 
is  mitigated  by,  an  attack  of  uratic  arthritis. 

Sydenham  noted  the  peculiar  mental  conditions  sometimes 
associated  with  gout.  "  The  mind  suffers  with  the  body,  and 
which  suffers  most  it  is  hard  to  say.  So  much  do  the  mind  and 
reason  lose  energy,  as  energy  is  lost  by  the  body,  so  susceptible 
and  vacillating  is  the  temper,  such  a  trouble  is  the  patient  to 
others  as  well  as  to  himself,  that  a  fit  of  gout  is  a  fit  of  bad 
temper.  To  fear,  to  anxiety,  and  to  other  passions  the  gouty 
patient  is  the  continual  victim,  while,  as  the  disease  departs,  the 
mind  regains  tranquillity." 

Hypochondriasis  is  not  commonly  met  with  in  the  fair-skinned, 
"  sanguine  arthritic,"  type  of  body,  where  the  circulation  is 
vigorous  and  the  mind  usually  active.  It  is  more  apt  to  occur 
in  lean,  sallow,  or  dark-skinned  persons,  where  the  circulation  is 
feeble  and  nervous  energy  is  less  active.  In  such  patients  there 
is  often  some  degree  of  hepatic  inadequacy,  the  digestion  is  feeble, 
and  small  dietetic  errors  are  quickly  and  severely  felt.  Oxaluria 
is  not  infrequent.  There  is  gouty  heritage,  but  often  incomplete 
manifestation  of  the  disorder  in  such  sufferers. 

It  is  well-recognized  that  much  depression  of  spirits,  without 
due  cause,  is  apt  to  overwhelm  some  gouty  subjects.  They  are 
"  under  a  cloud,"  moody,  and  lugubrious  from  time  to  time. 
Their  outlook  is  gloomy,  and  only  the  darkest  side  of  events  is 
visible  for  the  time  being.  Such  symptoms  "  grow  up,"  as  it 
were,  occasionally,  and  a  purge  is  the  best  treatment  for  this 
"  moping  melancholy." 1 

I  have  learned  to  regard  this  condition  rather  as  a  phase  of 
incomplete  gout  than  as  one  alternating  with  regular  arthritic 
attacks,  and  as  exhibiting  a  manifestation  of  the  gouty  habit 
derived  from  inheritance. 

Lecorche  observes  that  hypochondriasis  in  the    gouty  is    not 

1  Milton. 


HYPOCHONDRIASIS.       HYSTERIA.  233 

wholly  imaginary,  but  "  reposes  on  a  basis  of  sufferings  which 
are  only  too  real."  The  varied  minor  ailments  common  in 
incomplete  gout  become  magnified  and  exaggerated  in  import- 
ance. Eegular  fits  of  gout  but  rarely,  and  imperfectly,  relieve 
this  condition.  As  pointed  out  by  W.  Gairdner,  "  the  same  habit 
which  prevents  the  attack  makes  a  lingering  paroxysm."  The 
latter  author  recorded  several  instances  of  hypochondriasis  in  the 
gouty,  and  noted  that  the  sufferers  were  gluttonous  eaters,  and 
that  their  gout  was  of  an  atonic  character.  He  noted  every 
degree  of  this  affection,  from  the  gentlest  solicitude  about  health 
to  the  deepest  despondency.  In  common  with  other  careful 
observers,  he  referred  to  the  frequency  of  hypochondriasis  and 
hysteria  in  women,  especially  at  the  menopause. 

I  have  already  mentioned  the  case  of  a  lady  of  arthritic 
inheritance  who  developed,  temporarily,  symptoms  of  Graves' 
disease,  and  was  markedly  hysterical  throughout  her  married 
life,  and  after  the  cessation  of  the  catamenia.  She  was  com- 
monly in  a  desponding  and  gloomy  frame  of  mind. 

Hysteria  or  neuromimesis,  in  its  many  varieties,  is,  without 
doubt,  a  very  frequent  disorder  in  the  female  descendants  of  the 
gouty.1  I  have  of  late  regularly  inquired  as  to  this  point  in  cases 
that  have  come  before  me,  and  I  can  affirm  confidently  as  to  the 
connection  between  the  two  conditions  in  many  instances.  The 
symptoms  may  appear  soon  after  puberty,  or  at  any  time  up  to 
and  after  the  menopause.  The  daughters  of  gouty  fathers  present 
the  majority  of  instances.  Garrod  has  noted  cases  where  spinal 
tenderness  and  articular  symptoms  have  clearly  alternated  with 
each  other.  Laycock  insisted  on  the  fact  that  the  arthritic  dia- 
thesis predisposed  women  to  anomalous  forms  of  hysteria,  and  his 
opinion  was  the  result  of  long- continued  study  of  the  whole  sub- 
ject. 

The  leading  features  in  these  cases  are  a  feeble  state  of  the 
circulation,  and  a  delicacy  of  nervous  system.  It  is  not  essential 
that  luxurious  habits  should  have  been  indulged  in,  since  cases 
occur  in  the  families  of  the  poor.  Errors  in  diet  and  faulty 
methods  of  education,  both  of  mind  and  body,  have,  doubtless, 
much  to  do  with  the  induction  of  hysteria ;  but  there  is  probably 
inherent  defect  in  the  generation  and  flow  of  nervous  eneroy  in 
all  cases. 

1  "  It  has  been  supposed  by  some  writers  that  the  daughters  of  gouty  parents  are 
more  prone  than  others  to  hysteria,  This  may  be  partly  accounted  for  by  deficiency 
of  constitutional  energy  derived  from  the  parent,  and  greater  susceptibility  of  the 
nervous  system."— Diet,  of  Pract.  Med.,  Copland,  Art.  "Hysteria,"  p.  283. 


234  GOUT   IN   RELATION   TO    VARIOUS    NEUROSES. 

The  occurrence  of  hysteria  amongst  the  subjects  of  arthritic 
inheritance  appears  to  furnish  additional  evidence  of  the  implica- 
tion of  the  nervous  system  in  the  varying  manifestations  of 
gouty  disease. 

In  cases  of  painful  joints  occurring  in  hysterical  women  (arthro- 
pathia hysterica)  it  is  not  improbable  that  the  localized  determi- 
nation may  here  be  specially  significant  of  arthritic  inheritance. 

The  majority  of  cases  present  an  asthenic  type  even  when  there 
is  present  a  misleading  appearance  of  robustness. 


The  Incidence  of  Gout  in  Paralysed  Limbs. 

It  has  been  stated  that  acute  gout  does  not  occur  in  paralysed 
limbs ; *  but  my  own  experience,  with  that  of  other  observers,  is 
distinctly  contradictory  of  the  assertion. 

M.  Landr^-Beauvais  in  his  "These"  (i  800)  relates  a  very  note- 
worthy instance  in  support  of  the  fact  that  gout  may  attack  a 
paralysed  limb.  It  was  that  of  a  woman  who  had  three  paralytic 
seizures  (right  hemiplegia),  the  first  at  twenty-five  years  of  age, 
the  second  at  fifty.  After  the  latter,  the  right  limbs  became  the 
seat  of  vague  pains,  recurring  at  intervals.  At  the  age  of  seventy- 
four  there  was  a  third  attack  of  hemiplegia  on  the  same  side,  and 
some  months  afterwards  the  pains,  which  had  affected  several 
joints  of  the  paralysed  side,  settled  in  the  malleoli,  with  redness, 
and  swelling.  Acting  on  empirical  advice,  the  patient  placed  her 
feet  in  a  very  hot  bath.  The  pain  and  swelling  disappeared,  but 
in  two  hours  she  was  seized  with  violent  pains  in  the  stomach 
and  a  sense  of  constriction  at  the  epigastrium.  No  relief  was 
obtained  from  treatment,  and  death  followed  on  the  eighth  day. 
At  the  autopsy,  the  stomach  and  intestines  were  found  inflamed, 
thickened,  and  sphacelated  in  places. 

In  the  case  of  a  man  under  my  care  in  hospital,  who  was 
admitted  with  left  hemiplegia  of  recent  onset,  general  arterial 
sclerosis,  and  granular  kidneys,  acute  gout  came  on  in  both  wrists, 
and  followed  an  ordinary  course. 

Lecorche  records  the  case  of  a  man,  aged  thirty-nine,  of  gouty 
heritage,  who  had  right  hemiplegia  after  a  fall  from  his  horse 
at  the  age  of  eighteen.  He  had  had  rheumatic  fever  when  he 
was  sixteen,  and  syphilis  four  years  later.  Gout  attacked  the 
great  toe  of  the  paralysed  leg,  and  a  month  afterwards  the  left 
great  toe  ;  subsequently,  he  had  four  attacks  in  the  right  great  toe. 

1  The  late  Dr.  Leared  affirmed  this. 


GOUT    IN    PARALYSED    LIMBS.  235 

Metastasis  occurred  to  the  intestines  in  one  attack,  and  the  acute 
pains  there  ceased  on  return  of  the  process  to  the  foot. 

The  following  cases  illustrate  the  incidence  of  attacks  on  the 
sound  side.  A  man,  aged  seventy,  with  left  hemiplegia,  who 
was  under  my  care,  had  acute  gout  in  the  right  great  toe-joint. 
A  man,  aged  thirty-five,  admitted  into  hospital  for  left  hemiplegia, 
had  several  attacks  of  gout  in  the  right  great  toe-joint,  right  harjd, 
and  phalangeal  joints.  On  one  occasion  he  had  some  pain  in  the 
left  knee.  Both  parents  were  gouty.  There  was  no  albuminuria. 
The  man  suffered  from  lead-impregnation,  owing  to  his  work  as 
a  leather-cutter  being  done  on  lead,  and  he  probably  had  granular 
kidneys  and  cerebral  hemorrhage. 

In  the  following  case  of  left  hemiplegia,  attacks  of  gout 
occurred  on  both  sides  of  the  body. 

Gout  in  Paralysed  Limbs. 

George  Ingall,  set.  fifty,  by  trade  an  optician,  was  admitted  into  Mark  "Ward  on 
February  22,  1 88 1,  suffering  from  well-marked  left  hemiplegia. 

According  to  his  statement,  he  was  fairly  well  up  to  the  17th  instant,  though  for 
£i  day  or  two  previously  he  had  suffered  from  a  dull  headache.  Working  as  usual  on 
the  day  mentioned,  he  was  seized  with  trembling  and  nervousness,  and  about  half 
an  hour  afterwards  fell  down  semi-unconscious,  and  was  unable  to  raise  himself, 
having  lost  the  power  of  his  left  arm  and  leg.  His  memory  seems  to  have  been 
affected,  and  he  appears  to  have  confused  ideas  of  what  happened  between  this  and 
the  time  he  was  admitted  into  the  hospital. 

Previous  history. — Five  years  ago  he  had  sunstroke  on  a  voyage  from  Africa,  and 
was  ill  for  three  weeks.  Two  years  ago  had  a  fit  (epileptic  ?).  A  month  or  two  ago 
he  noticed  a  puffiness  about  his  eyelids  ;  but  his  feet  have  never  swelled.  Of  late 
he  has  been  subject  to  drowsiness.     Has  had  two  attacks  of  gout. 

Family  history. — Father  died  of  some  liver  complaint  at  the  age  of  forty-six. 
Mother  died  at  fifty-two.  Brothers  and  sisters  healthy.  Does  not  know  of  any 
paralysis  or  gout  in  family. 

On  admission  he  was  a  man  of  medium  stature,  with  a  fairly-nourished  body. 
Hair  dark,  eyes  brown,  complexion  sallow,  skin  soft  and  dry. 

The  paralysis,  which  affected  the  left  side  of  the  body,  was  more  marked  in  the 
upper  extremity  than  in  the  lower.  The  arm  was  swollen  and  painful,  and  any 
attempt  to  move  it  caused  pain.  Though  motion  was  much  impaired  in  the  leg, 
he  could  move  it  voluntarily,  but  was  quite  unable  to  stand.  Sensation,  though 
impaired  over  the  paralysed  side,  was  still  preserved,  though  discriminating  power, 
for  the  most  part,  was  lost. 

Patella-reflex  present,  and  also  skin-reflex.     Ankle-clonus  absent. 

The  left  side  of  the  face  was  also  paralysed,  with  the  exception  of  the  occipito- 
frontalis  and  orbicularis.  Articulation  was  affected,  but  deglutition  was  performed 
without  difficulty. 

Chest. — Inspection  showed  that  the  left  side  expanded  to  a  less  degree  than  the 
right.     Palpation,  percussion,  and  auscultation  normal. 

Heart. — Area  of  dulness  increased  downwards  and  outwards.  Apex  beat  two 
inches  below  the  nipple.  First  sound  reduplicated  at  apex.  Second  sound  short  and 
sharp.  Sounds  of  reduplication  become  less  marked  towards  base,  and  at  base 
cannot  be  heard. 

Abdomen  natural.     Some  slight  tenderness  over  liver. 


236  GOUT    IN   RELATION   TO    VARIOUS   NEUROSES. 

Tongue  slightly  furred.     Appetite  good. 

Bowels  regular.     Urine,  acid,  sp.  gr.  1015  ;  albumen  ^th. 

Treatment — confined  to  bed  and  ordered  milk  diet. 

February  24. — The  right  hand  and  wrist  swollen,  inflamed,  and  painful.  The  left 
hand  in  the  same  condition.  Has  passed  a  good  night.  Pulse  70.  Tongue  furred. 
Albumen  in  urine  ^th. 

February  25. — Slept  well.  Hand  as  yesterday.  Has  had  it  wrapped  up  in  cotton 
wool.  Albumen  in  urine  -g-th.  Ordered  tinct.  colchici  ttixx.  out  of  haust.  calumb. 
alkal.  ter  die. 

February  26. — Slept  well  last  night,  and  sleeps  a  good  deal  in  daytime.  Very 
little  pain  in  left  hand.  Right  hand  still  painful.  Last  night  passed  water  in  bed 
unconsciously,  but  micturition  normal  this  morning.  Tongue  furred  thickly.  Tem- 
perature 100. 6°  last  night,  normal  this  morning.  Pulse  84.  Bowels  not  open  since 
yesterday.     Ordered  haust.  sennse  co.  5iss-     Albumen  ^th. 

February  28. — Has  slept  well.  Tongue  furred.  Hands  much  better,  no  pain. 
Albumen  in  urine  ^V^h-     Bowels  open.     Temperature  normal. 

March  I. — Continues  to  sleep  well.  Bowels  open.  Tongue  still  furred.  Both 
hands  in  much  the  same  condition,  as  28th  ult.  Urine  sp.  gr.  1015.  Albumen 
a  trace. 

March  2. — Has  passed  if  pint  of  urine  from  10  A.M.  yesterday  to  10  A.M.  to-day. 
Albumen  a  trace.     Hands  somewhat  better. 

March  4. — Much  better.  Swelling  in  wrists  nearly  subsided.  No  pain  except  a 
slight  twinge  now  and  then.  Tongue  clean.  Pulse  72.  Bowels  not  open  for  two 
days.     Ordered  haust.  sennse  co.  giss. 

March  7. — Hands  nearly  all  right.  Passes  from  oiiss.  to  oiij.  of  urine  per  diem. 
Albumen  a  trace. 

March  10. — Hands  quite  well.  General  health  good.  The  colchicum  mixture 
stopped.  Patient  can  move  his  leg  much  better,  and  the  arm  somewhat.  Face  also 
much  improved. 

On  the  evening  of  24th,  patient  had  a  slight  attack  of  gout  in  left  great  toe,  up  till 
which  time  his  condition  had  greatly  improved.  Colchicum  mixture  was  again 
ordered,  and  patient  was  all  right  again  on  26th. 

From  this  time  up  till  the  day  he  left  the  hospital  (April  19)  he  greatly  improved. 
He  had  no  more  attacks  of  gout,  and  left  not  cured  of  his  paralysis,  but  greatly 
relieved  by  treatment. 

It  is  not  improbable  that  gout  may  sometimes  have  been  sus- 
pected in  cases  of  paralysis  where  arthritis  has  come  on  in  con- 
nection with  the  cerebral  lesion,  constituting  examples  of  Charcot's 
arthropathia  des  himipUgiqiLes}  Scott  Alison  directed  attention  to 
such  cases  in  1846  (Lancet,  January  16). 

Charcot  relates  a  case  of  a  woman,  aged  forty-nine,  suddenly 
seized  with  hemiplegia.  Some  days  afterwards  pain,  heat,  and 
swelling  occurred  in  the  wrist,  then  in  the  knee  and  foot  of  the 
paralysed  limb.  The  limbs  were  slightly  rigid.  Cerebral  soften- 
ing was  found  after  death.  In  the  renal  pelves  were  numerous 
uric  acid  calculi.  The  same  author  also  records  the  following 
cases  : — A  man,  aged  fifty-four,  a  painter,  suffering  from  saturnine 
gout,  became  suddenly  hemiplegic.  Shortly  afterwards,  the  wrist, 
hand,  and  foot   of  the   paralysed   side  were  attacked  with  gout. 

1  Legons  sur  les  Maladies  du  Systeme  nerveux,  torn,  i.,  Paris,  1877,  p.  114. 


GOUT   IN    PARALYSED    LIMBS.  237 

The  affected  limbs  were  rigid.  Haemorrhage  was  found  in  the 
brain. 

A  woman,  aged  about  forty,  had  right  hemiplegia  with  aphasia 
of  three  years'  duration,  the  limbs  being  very  rigid.  Attacks  of 
pain  and  swelling  occurred  in  several  of  the  joints  of  the  paralysed 
side.  At  the  autopsy,  signs  of  old  cerebral  haemorrhage  were 
found,  and  the  cartilages  of  the  affected  joints  were  encrusted  with 
crystallized  and  amorphous  urates.  There  were  no  deposits  in 
the  cartilages  of  the  joints  of  the  sound  limb,  but  some  were  found 
in  the  kidneys. 

In  all  these  cases  there  can  be  little  doubt  as  to  the  truly  gouty 
nature  of  the  concomitant  arthritis,  and  of  its  determination  to  the 
paralysed  limbs.  M.  Charcot  is  careful  to  state  in  respect  of  these 
examples  that  they  were  quite  exceptional,  and  very  different  from 
those  in  which  arthritis  occurred  without  rheumatic  or  gouty  taint, 
and,  solely,  as  a  concomitant  of  the  brain-lesion. 

The  following  case,  recorded  by  M.  Bourneville,  is  important.1 
It  was  that  of  a  woman,  aged  fifty-four,  who  had  had  an  attack  of 
right  hemiplegia  five  years  previously  with  aphasia,  probably  due 
to  cerebral  haemorrhage.  A  second  and  fatal  apoplexy  occurred. 
At  the  autopsy,  a  large  fresh  haemorrhage  was  found  in  the  brain, 
extending  into  all  the  ventricles.  In  the  knee  and  great-toe  joints 
of  the  right  (paralysed)  limb  were  found  uratic  encrustations,  but 
none  were  detectible  in  the  corresponding  joints  of  the  left  limb. 
The  kidneys  appeared  natural,  with  the  exception  of  uratic  streaks 
in  some  of  the  tubules.  In  the  knee  the  synovia  was  bloody,  and 
bony  outgrowths,  with  "  lipping,"  were  found.  M.  Bourneville 
was  of  opinion  that  the  deposits  were  locally  determined  by  the 
paralytic  state  of  the  limb. 

I  fully  recognize  the  occurrence,  occasionally,  of  arthropathy  in 
hemiplegia,  and  I  would  suggest  that  the  same  theory  of  its  pro- 
duction be  entertained  in  cases  where  gouty  arthritis  supervenes 
in  paralysed  limbs.  The  nervous  element  appertaining  to  gout  is 
here  often,  if  not  always,  the  determinant  factor  in  localization. 
Exceptions  occur,  but  they  do  not  invalidate  the  general  rule  in 
such  cases. 

My  hospital  experience  has  supplied  me  with  other  instances  in 
which  gout  has  alighted  on  paralysed  limbs. 

1  Etudes  cliniques  et  thermom6trlques  sur  les  Maladies  du  Systeme  nerveux.    Paris, 
1872,  p.  58. 


138  GOUT   IN    RELATION    TO   VARIOUS   NEUROSES. 


Recoverable  Paraplegia  in  a  Gouty  Man. 

Dr.  Wilks  records  a  case  of  recovery  from  paraplegia  in  a  man,  set.  fifty-two,  who 
was  subject  to  gout  and  had  not  had  syphilis.1  A  month  before  he  went  into  Guy's 
Hospital  he  had  gout  in  the  feet,  and  after  two  weeks  was  losing  power  of  the  legs 
and  bladder.  The  paralysis  rapidly  increased.  On  admission  he  could  not  move  his 
legs.  There  were  partial  anesthesia  as  high  as  the  umbilicus,  and  well-marked  re- 
flexes. The  urine  was  drawn  off  twice  daily  and  was  ammoniacal.  Girdle-sensation 
and  numbness  ensued,  passing  down  arms  to  fingers.  The  patient  got  worse,  became 
feverish,  had  rigors,  hiccup,  and  a  red  tongue.  A  bed-sore  formed,  and  the  mind  was 
clouded.  Suppurative  nephritis,  by  extension  from  the  bladder,  was  suspected.  Was 
very  ill  for  some  days,  when  symptoms  abated,  and  some  power  in  legs  returned. 
Rapid  recovery  followed,  and  use  of  catheter  became  unnecessary.  The  patient 
began  to  stand,  and  to  walk  on  crutches,  and  left  the  hospital  two  months  after 
admission,  or  six  weeks  after  his  paraplegia  was  complete. 

It  is  not  easy  to  surmise  the  cause  of  the  ruyelitis  which 
occurred  iu  the  case  just  recorded,  and  we  have  no  knowledge,  as 
yet,  to  warrant  the  belief  in  meningo-myelitis  due  to  gouty  inflam- 
matory change.  I  conceive  it  to  be  possible,  however,  for  such  a 
disorder  to  occur. 


Idiosyncrasy  in  Relation  to  Gouty  Proclivity. 

One  of  the  most  noteworthy  features  attaching  to  gouty  ten- 
dency is  that  of  idiosyncrasy.  The  whole  subject  is  a  large  one, 
and  would  well  repay  more  accurate  and  scientific  study  than  it 
has  yet  received.  It  can  only  be  generally  referred  to  here.  I 
allude  to  it  in  this  chapter  because  I  conceive  that  the  nervous 
system  is  essentially  concerned  with  the  special  peculiarities  under 
consideration.  There  are  always  present  the  personal  and  indi- 
vidual factors,  each  person  being  a  law  to  himself. 

In  respect  of  gout,  the  very  general  inability  to  partake  of 
certain  alcoholic  fluids  is  idiosyncratic  to  the  mode  of  tissue- 
metabolism  attaching  to  persons  thus  impressed. 

The  variety  of  personal  peculiarities  in  respect  of  food  (includ- 
ing flavours  and  odours),  air,  water,  medicines,  climatic  and  other 
environments,  met  with  in  the  gouty,  is  great  and  quite  remark- 
able. For  purposes  of  treatment,  it  is  important  to  take  note  of 
any  one  of  these  that  may  be  manifested.  I  suppose  that  no  other 
known  diathetic  state  has  so  much  of  idiosyncrasy  attaching  to  it 
as  gout. 

Many  of  the  dietetic  peculiarities  recognized  are  met  with  in 
the  gouty  or  their  descendants.  These  may  occur  at  an  early 
period  of  life,  or  may  supervene  at  any  time,  and   it  is  certain 

1  Diseases  of  Nervous  System,  p.  229,  1878. 


GOUTY  IDIOSYNCRASY.  239 

that  they  may  last  for  a  term  and  completely  disappear.  We 
have,  therefore,  to  note  a  certain  periodicity  as  attaching  to  idio- 
syncrasy, inability  present  at  one  time  of  life  yielding  completely 
by  lapse  of  time.  Such  periodicity  is  also  seen  in  certain  gouty 
ailments  which  are  the  appanage  at  one  time  of  youth,  and  pass 
off,  to  yield,  perhaps,  to  fresh  proclivity  or  idiosyncrasy.  Examples 
in  proof  of  this  are  recognized  in  the  tendency  to  sore  throat, 
hepatic  disturbance,  loathing  for  animal  food  in  childhood  and 
early  adult  age,  in  megrim-tendency  of  early  and  adult  life,  which 
yields  in  middle  life,  and  in  carbuncle  and  glycosuria,  which  are 
apt  to  supervene  in  more  advanced  life. 

The  facts  relating  to  gouty  idiosyncrasy  throw  a  strong  light 
on  the  nervous  element  which  figures  so  largely  as  a  factor  in  the 
whole  disease. 

It  may  be  boldly  affirmed  that  there  are  no  known  means 
whereby  an  idiosyncrasy  may  be  overcome.  The  peculiar  nervous 
potentiality  is  in  possession  so  long  as  the  peculiarity  endures. 

Our  knowledge  of  its  natural  history  affords  warrant  for  the 
belief,  or  at  any  rate  for  the  hope,  that  in  course  of  time  it  may 
yield  and  pass  away.  While  it  is  present,  it  has  to  be  reckoned 
with  as  a  dominating  factor,  and  must  be  regarded  as  a  special 
form  of  nervous  impressibility — a  part,  as  I  believe,  of  the  peculiar 
gouty  neuro-trophic  habit. 


CHAPTER  XL 

SUGGESTIVE  METHOD  FOR  INVESTIGATION  OP 
CASES  OP  GOUT. 

Gout — Clinical  history — Evidence  of  family  predisposition — Here- 
dity— Modification  by  transmission — Association  ivith  other 
diseases;  e.g.,  commingling  with  rheumatism,  struma,  cancer; 
gout  cross-tainted  with  syphilis  or  other  diseases. 

Initials  of  patient.  M.  or  F.  Age. 

Residence. 

Occupation  of  patient  and  parents  (especial  reference  to  alcoholic 
excess,  or  exposure  to  lead-  or  lime-impregnation). 

Total  abstainer,  how  long  1 

Stout,  moderate,  spare.     Strong,  moderate,  weak. 

Complexion,  vascularity,  pallor. 

Head,  large. 

Integumentary  System. — Complexion,  vascularity,  pallor,  mixed.  Hair, 
colour,  date  of  greyness,  baldness.  Head,  large.  Temporal  artery,  tor- 
tuous. Skin,  thick,  smooth,  very  smooth.  Ears,  undue  hardness  of, 
tophi,  condition  of  meatus,  deafness.  Eyes,  arcus  senilis,  conjunctival 
oedema,  suborbital  oedema.  Nails,  coarsely  striated,  smooth,  brittle. 
Nose  thickened  at  end.  Eczema,  eczematous  ulcer,  painful  at  night. 
Urticaria.  Lichen.  Herpes.  Psoriasis.  Pruritus.  Pruritus  ani.  Pru- 
ritus vulvse. 

Eyes. — Condition  of  iris,  old  iritis,  adhesions.  Cataract.  Retinal 
changes.  Flame-shaped  haemorrhages  on  disc.  Glaucoma.  Conjunctival 
ecchymoses,  episcleritis,  sclerotitis,  ophthalmitis. 

Articular  System. — Suppleness  generally  in  neck,  spine,  limbs,  and 
extremities.  Cracklings  on  movement,  e.g.,  in  spine.  Condition  of 
metacarpo-phalangeal  and  phalangeal  joints,  as  to  knottiness,  distortion, 
altered  axes.  Fluid  or  tophitic  effusions,  bony  enlargements,  oedema, 
ankylosis.  Heberden's  nodes  in  true  gout.  Deflection  of  digits  to 
ulnar  aspect,  or  not.  Great  toe-joints,  deflected  outwards,  or  not,  enlarge- 
ment,  crackling.     Condition  of  bursal  sacs  as  to  thickening,  effusion, 


CLINICAL   STUDY    OF   GOUT.  24 1 

tophi.     Pellucid  cysts  near  joints.     Ankylosis,  true,  (synostosis)  or  false. 
Periostitis.     Dupuytren's  contraction  of  palmar  fascia.     Nodules. 

Lymphatic  System. — Condition  to  be  noted  in  cases  untainted  by 
struma.     Leuchamiia,  splenic  and  lymphatic. 

Circulatory  System. — Heart,  position  of  apex-beat ;  signs  of  enlarge- 
ment. Sounds,  pure,  reduplicated,  aortic  second  sound,  character.  Val- 
vular lesion.  Pulse,  quality,  rhythm,  condition  of  arterial  coats,  tension. 
Angina  pectoris.  Veins,  venous  remora.  Varix.  Phlebitis.  Palpitation, 
cardiac,  thyroideal,  and  in  abdominal  aorta.  Sphygmograms.  Haemo- 
philia.    Graves'  disease. 

Respiratory  System. — Tendency  to  quinsy  in  early  life;  one-sided 
tonsillitis.  Laryngeal  catarrh.  Bronchial  catarrh.  Emphysema.  Pneu- 
monia and  character  of  sputa.  Dry  pleurisy.  Haemoptysis.  Epistaxis 
in  early  life,  or  at  any  period.  Spasmodic  asthma.  Phthisis,  family 
history.     Commingling  of  gout  and  phthisis. 

Digestive  System. —  Teeth,  regular,  massive,  small,  -well-enamelled, 
colour,  worn  down,  freedom  from  caries,  or  reverse ;  sound  teeth  ever 
extruded  ;  "  buck  teeth  ;  "  alveolar  absorption,  tenderness,  gums  retracted, 
blue  line  (lead),  tartar.  Tongue,  conditions  of  :  undue  dryness  at  times, 
deep-seated  pain  in ;  psoriasis  of ;  neuralgia  of.  Fauces,  unduly  red, 
coarsely  granular.  Uvula,  long,  glossy.  Parotitis.  Saliva,  sulpho- 
cyanide  of  potassium  in  excess.  Pharynx,  condition  of  mucous  mem- 
brane. (Esophagismus.  Gastric  digestion,  acidity.  Intestinal  digestion, 
much  flatulence,  effects  of  various  wines  and  beer,  cardialgia.  Idio- 
syncrasies as  to  food.  Gastralgia.  Liver,  natural,  tender  on  palpa- 
tion. Hepatic  colic.  Gall-stones.  Enteritis,  colic.  History  of  bilious 
attacks ;  hypochondriac  fulness  ;  shoulder-tip  pains  ;  omentum  and  ab- 
dominal parietes  fatty.  Bowel-evacuation,  colour  and  character  of  stools. 
Diarrhoea.     Hsemorrhoidal  tendency. 

Genito-Urinary  System. — Penal  pain,  as  distinct  from  lumbar  pain 
due  to  other  causes.  Calculi.  Gravel.  Urine,  character,  quantity,  &c, 
before  attack,  during,  and  in  intervals,  colour,  reaction,  sp.  gr.,  deposit, 
casts,  albumen,  glucose,  urates,  oxalates,  urea,  uric  acid ;  cystitis. 
Quantity.  Nocturnal  micturitions.  Bladder,  irritable.  Haernaturia. 
Prostatitis  with  retention  of  urine  ;  stricture ;  fibroid  thickening.  Pria- 
pism (nocturnal).  Urethra.  Thrombosis  in  corpus  cavernosum.  Herpes 
or  eczema  of  glans.  Excessive  venery  in  early  life.  Varicocele. 
Orchitis.  Gonorrhoea,  gleet,  characters  of,  if  intractable.  Menorrhagia. 
Amenorrhoea.     Vicarious  haemorrhages. 

Nervous  System. — Temperament,  cheerful  or  melancholic  disposition. 
Hypochondriacal  tendency.  Hysteria.  Temper.  Energy.  Sensitive- 
ness to  pain.  Mental  power  and  capacity.  Neurotic  history  in  rela- 
tives or  patient  (insanity,  epilepsy,  hemicrania,  neuralgia,  angina  pectoris, 
spasmodic  asthma).  Sleep,  tooth-grinding  during,  startings  in,  somnam- 
bulism. Cramps  in  calves  or  elsewhere.  Fleeting  pains  in  knuckles,  &c. 
Pain  in  heel,  tendo  Achillis,  in  xiphoid  cartilage.     Sensations  of  burning 

Q 


242      SUGGESTIVE    METHOD    FOR   INVESTIGATION    OF    CASES. 

in  palms,  thighs,  and  soles.  Tickling  and  pain  in  palate.  Lumbago. 
Sciatica.  " Pins  and  needles "  sensation.  Numbness.  "Dead  fingers." 
Vertigo.  Neuralgia  of  fifth  and  great  occipital  nerves.  Neuritis. 
Parsestbesiae.     Convulsions. 

Nervous  symptoms  premonitory  of  attack. 

Family  History. — Gout.  Osteo-arthritis.  Eheumatic  fever  or  any 
arthritic  condition.  "Chalky"  gout.  Diabetes.  Dietetic  habits  and 
residence  of  ancestry.  History  of  any  members  who  have  lived  out  of 
British  Islands.  Ages  at  which  gout  appeared.  If  younger  members 
suffered  earlier  and  more  severely.  Medical  history  of  ancestors  as  fully 
as  possible. 

In  Women. — Health  during  menopause.  First  gouty  manifestations, 
if  articular,  where  1 

Chronic  Gout. — Tendency  to  polyarthritis,  simulating  general  rheuma- 
tism. Modifications  of  attacks.  Alternations  with  any  neurotic  attacks  ; 
substitutive  manifestations.     Glycosuria. 

Visceral  Attacks. — Gastric.  Hepatic.  Enteric.  Pulmonary.  Vesical. 
Encephalic. 

Climatic  Influences. — Season,  special  influences  of  cold,  east  wind, 
damp ;  of  mountain  and  sea  air.  Town  and  country  life.  Gout  in 
India,  Tropics,  and  Colonies. 

Dietetic  Influences. — Fish-eaters.     Vegetarians.     Meat-eating. 

Occupation. — Profession.     Habits,  active,  sedentary.     Open-air  life. 


CHAPTER  XII. 

PREMONITORY  SIGNS  OP  GOUT -CLINICAL  VARIE- 
TIES OP  GOUT-ACUTE  (REGULAR)  AND  CHRONIC 
(A.  TOPHACEOUS,  B.  DEFORMING)  GOUT -GOUTY 
CACHEXIA-IRREGULAR  (INCOMPLETE)   GOUT. 

Premonitory  Signs  of  Gout. 

The  precursory  symptoms  of  sthenic  gout  in  the  earlier  attacks 
are  few  and  little  marked.  In  later  attacks  these  are  more  pro- 
nounced, and  also  better  heeded  by  the  patient.  The  earliest 
warnings  come  from  the  digestive  and  circulatory  systems.1  Some 
degree  of  dyspepsia  is  commonly  noted,  accompanied  by  a  sense 
of  fulness  at  the  epigastrium  and  in  the  hepatic  region.  Heart- 
burn, sour  eructations,  and  flatulency  are  the  leading  dyspeptic 
indications.  There  may  be  headache.  The  urine  is  apt  to  be 
charged  with  lithates.  Irregular  action  of  the  heart  is  observed, 
with  throbbing  and  palpitation,  these  irregularities  of  impulse 
being  felt  in  the  head,  especially  on  exertion.  The  pulse  is  apt 
to  be  firm  or  tense.  Sighing  expiration  is  sometimes  present. 
Haemorrhoids  may  occur.  On  the  side  of  the  nervous  system  are 
found  mental  depression,  neuralgia,  hemicrania,  drowsiness  and 
yawning,  deep-seated  pains  in  various  parts,  sometimes  violent, 
and  of  momentary  duration.  These  may  be  felt  in  the  limbs  or 
feet,  or  in  the  joints  of  the  fingers.  Pain  in  the  calcaneum  and 
plantar  fascia  is  characteristic  of  gout,  and  so  is  general  pruritus. 
Lumbar  pain,  toothache  in  sound  teeth,  sharp  pains  in  the 
tonsils  and  many  other  parts  may  likewise  be  warnings  of  a 
paroxysmal  attack.  Some  sallowness  of  the  face  and  icteric  tint 
of  conjunctivae  may  be  observed.  Ptyalism  was  noted  by  Scuda- 
more.  The  bowels  are  often  confined,  and  the  stools  pale.  As 
articular  pains  supervene,  dyspeptic  symptoms  may  pass  away. 
The  appetite  has  often  been  observed  to  be  unusually  good  the 

1  "Its  only  forerunner  is  indigestion  and  crudity  of  the  stomach,  of  which  the 
patient  labours  some  weeks  before." — Sydenham,  op.  cit. 


244  CLINICAL    VARIETIES    OF    GOUT. 

day  before  the  paroxysm,1  and  a  general  sense  of  bien-etre  or 
euphoria — too  commonly  a  bad  sign  in  many  diseases — may  be 
experienced.  As  a  rule,  scanty  secretion  of  concentrated  urine  is 
observed  before  an  attack ;  but  free  urination  sometimes  precedes 
a  gouty  fit.  I  have  observed  this  sometimes,  and  Scudamore 
believed  that  it  seldom  occurred  except  in  persons  of  nervous 
temperament  whose  constitutions  had  been  much  weakened  by 
gout.  My  experience  supports  this  view.  Graves  recorded  two 
examples  of  this  in  hereditary  cases.2 

Slightly  marked  attacks  of  ophthalmia,  affecting  the  sclerotic 
tunic  and  the  conjunctiva,  have  been  sometimes  noted  as  pre- 
cursors of  gout.  The  congestion  is  not  usually  wide-spread,  and 
is  chiefly  seen  near  the  insertions  of  the  orbital  muscles.  The 
nights  may  be  disturbed  by  various  dyspeptic  symptoms,  and  the 
sleep  is  not  refreshing.  The  mornings  are  unwelcome,  the  appe- 
tite fails,  errors  in  diet  are  quickly  recognized,  and  there  is  disin- 
clination to  face  the  common  duties  of  the  day.  As  psychical 
symptoms,  peculiar  irritability  and  shortness  of  temper  may  be 
witnessed,  and  mental  effort  is  difficult  and  laborious,  or  im- 
possible. 

As  might  be  expected,  these  symptoms  will  vary  according  as 
an  outbreak  is  determined  by  any  special  cause,  or  led  up  to  by 
some  peculiar  train  of  circumstances.  As  a  rule,  all  of  them  dis- 
appear with  the  onset  of  a  paroxysm  of  arthritis.  Such  predeter- 
mining causes  are  well-recognized.  Prolonged  mental  labour, 
undue  strain,  anxiety,  pressure  of  business,  confinement  in-doors, 
absence  of  wonted  exercise,  a  succession  of  indulgences  at  the 
table,  any  one  of  these,  or,  not  infrequently,  a  combination  of 
two  or  more  of  them,  may  readily  lead  up  to  a  sharp  attack  of 
gout. 

On  Determinants  of  Gouty  Paroxysms. 

Allusion  has  already  been  made  to  several  conditions  which 
appear  to  determine  articular  attacks  of  gout. 

Traumatism,  shocks,  bodily  and  mental,  loss  of  blood,  and  various 
ailments  are  amongst  some  of  the  recognized  determinants.  Many 
of  these  doubtless  induce  changes  in  the  nervous  system,  and  are 
of  a  character  to  upset  the  general  equilibrium  of  nutritive  pro- 
cesses throughout  the  body. 

Attacks  of  severe  influenza  have  been  noted  with  some  fre- 
quency to  be  followed  by  paroxysms  of  gout.     Amongst  the  many 

1  Scudamore  records  a  case  where  there  was  excessive  appetite  for  meat  two  or 
three  days  before  a  fit.  2  Clin.  Med. 


DETERMINANTS  OF  GOUTY  PAROXYSMS.       245 

proclivities  of  those  suffering  from  incomplete  gout  is  a  tendency 
to  such  catarrhal  attacks  as  are  commonly  called  "  had  colds," 
which  occur  especially  in  the  form  of  coryza  and  gravedo,  with 
sore-throat,  leaving  the  patient  weak  and  depressed  for  some 
weeks. 

Severe  purging  is  a  determinant,  especially  in  well-established 
gout.  Excessive  venery  is  thus  recognized.  Changes  of  accus- 
tomed habits  in  respect  of  exercise  and  diet,  be  they  either  in  the 
direction  of  excess  or  deficiency,  are  readily  provocative  in  those 
goutily  disposed.  Exposure  to  cold  with  check  to  perspiration  is 
sometimes  an  efficient  cause  of  a  fit  of  gout. 

Paroxysms  have  been  induced  with  remarkable  suddenness  by 
indiscretions  in  diet.  A  single  glass  of  champagne  has  been 
known  to  induce  an  attack  within  a  few  minutes.  In  such  a  case 
there  must  have  been  all  the  necessary  conditions  ready  for  the 
induction  of  a  fit.  The  train  was  fired,  as  it  were,  by  the  last 
addition  to  the  blood  of  such  matters  as  sufficiently  reduced  its 
alkalinity.  The  balance  of  health  is,  therefore,  very  readily  upset 
in  these  instances,  and  where  such  instability  exists,  other  than 
dietetic  errors  may  be  effective  as  determinants,  such  as  shocks, 
strong  emotions,  and,  indeed,  any  conditions  capable  of  producing 
profound  impressions. 

Hydropathic  treatment  is  frequently  a  cause  of  acute  paroxysms. 
This  is  well  recognized  at  the  various  Spas.  Change  of  habits  in 
diet  and  general  regimen,  together  with  the  special  influence  of 
baths  and  water-drinking,  suffice  to  induce  attacks,  and  these  are 
sometimes  found  to  be  so  far  salutary  as  to  clear  the  system,  and 
secure  a  more  lasting  immunity  from  future  paroxysms. 

Inflammation,  as  commonly  understood,  forms  no  essential  part 
of  the  pathology  of  gout — neither  does  pain.  Instances  of  une- 
quivocal gout  occur  in  which  changes  in  joints  take  place  without 
any  of  the  classical  symptoms  of  an  acute  paroxysm.  There  may 
be  intense  pain,  but  no  heat,  redness,  or  apparent  change  in  the 
affected  part,  and  the  pain  may  come  on  without  any  warning.1 
I  have  already  described  a  case  where    "  quiet "  gout  occurred 

1  Dr.  W.  Gairdner  was  familiar  with  such  cases,  and  gave  an  account  of  such  an 
attack,  during  dinner,  in  a  gentleman,  in  whom  sudden  agony  occurred  in  a  great  toe- 
joint.  The  pain  lasted  half  an  hour,  and  passed  off  as  suddenly  as  it  came.  No 
change  was  observable  in  the  joint.  No  warning  symptoms  had  been  present.  Very 
early  the  following  morning  the  other  great  toe- joint  was  similarly  attacked.  Three 
weeks  later  a  typical  attack  occurred  in  the  heel,  with  every  symptom  of  true  gout. 
He  quotes  another  case  from  van  Swieten's  Commentaries,  and  in  this  instance 
unequivocal  gout  followed  in  twelve  months.  From  these  and  other  cases  Dr. 
Gairdner  sought  to  prove  that  "  the  nature  of  gout  is  the  very  reverse  of  inflamma- 
tory."— Op.  cit,  3rd  edit.,  p.  139. 


246  CLINICAL   VARIETIES    OF   GOUT. 

gradually,  leading  to  severe  crippling  with  much,  uratic  deposit, 
and  where  no  pain  or  overt  gout  ever  occurred  in  the  parts. 

Prolonged  mental  labour  and  intense  study  may  precipitate  a 
fit.  As  Sydenham  remarked,  "  Quoties  enim  ad  heec  studia  me 
recipiebam,  toties  et  podagra  recurrebat."  Venassection  and  loss 
of  blood  are  to  be  reckoned  amongst  determinants. 

Acute  Gout. 

"  We  learn  acute  disease  from  seeing  it  as  a  whole  ;  from  seeing  it  as  it  is  acted 
and  suffered  through  all  its  stages  by  the  same  individual  men  and  women.  Being 
an  affair  of  a  few  days  or  a  few  weeks  only,  we  are  often  present  as  eye-witnesses  of 
it  from  first  to  last.  Thus  our  knowledge  of  it  is  drawn  from  single  and  complete 
histories." — Peter  Meke  Latham,  Diseases  of  the  Heart,  1846,  Lect.  xxxvi. 

This  constitutes  the  form  in  which  gout  is  commonly  regarded, 
the  classical  arthritis  or  podagra.1 

When  typically  manifested,  its  character  and  symptoms  are 
readily  recognizable,  and  should  not  be  confounded  with  any  other 
condition. 

In  a  first  attack,  however,  the  patient  himself  is  not  unfre- 
quently  sceptical  as  to  the  diagnosis.  It  may  be,  and  often  is, 
his  first  serious  ailment  of  adult  life.  He  has,  perchance,  prided 
himself  on  his  robust  constitution,  on  his  activity  and  muscular 
capacity,  and  would  fain  believe  that  he  is  as  yet  too  young  to  be 
the  victim  of  a  trouble  which  he  conceives  to  be  the  appanage  of 
advanced  years,  and  a  Nemesis  for  over-indulgence  in  the  good 
things  of  the  table. 

He  would  rather  believe  that  he  had  suffered  some  sprain  or 
direct  injury  to  the  part,  or  that  he  was  merely  "  rheumatic."  A 
second  attack  commonly  brings  conviction  to  the  sufferer,  and  he 
forthwith  acquiesces  in  his  fate. 

A  careful  consideration  of  the  several  features  of  a  well-marked 
case  should  prevent  mistakes  in  the  diagnosis  of  the  local  affec- 
tion, for  it  may  be  asserted  that  no  other  known  malady  attacks 
a  joint  after  the  manner  of  gout.  Other  forms  of  arthritis  may 
affect  the  gouty,  and,  thus,  difficulty  be  met  with,2  but  the  rule 
will  commonly  hold  good — a  suddenly  induced  acute  monarthritis 

1  Various  epithets  are  applied  to  this  form  of  gout,  e.g.,  "regular,"  "articular," 
"  frank,"  "  paroxysmal,"  "  sthenic." 

2  Such  an  instance  is  related  by  Paget,*  where  a  pyasmic  abscess  formed  near  a 
great  toe  consequent  on  tying  piles. 

*  Clin.  Lect.  and  Essays,  2nd  edit.,  p.  358. 


ACUTE   GOUT.  247 

is,  in  the  majority  of  instances,  an  unequivocal  manifestation  of 
true  gout. 

The  leading  features  of  a  regular  fit  of  the  gout  relate  more 
especially  to  its  peculiar  mode  of  onset,  the  specifically  intense 
painfulness,  and  the  locality  most  apt  to  be  the  seat  of  first 
attacks. 

No  description,  however  minute,  will  apply  to  the  symptoms 
met  with  in  each  case  of  a  fit  of  gout.  In  each  individual  affected 
by  disease  there  is  always  a  personal  element,  and  the  manner  of 
his  suffering  depends  on  one  or  more  factors  pertaining  to  his 
peculiar  habit  of  body,  inherited  tendencies,  age,  and  circum- 
stances. The  symptoms  are  much  modified  by  the  special  con- 
stitution of  the  nervous  system  as  to  sensitiveness  and  reaction  in 
each  person.  The  classical  attacks  described  by  Sydenham  are  by 
no  means  the  rule,  even  in  the  first  onset,  and  in  cases  that  may 
be  termed  sthenic.  The  nocturnal  paroxysm  is,  in  particular, 
less  often  met  with  than  would  be  imagined  if  the  ordinary 
accounts  of  the  text-books  were  to  be  implicitly  relied  on.  Sud- 
denness of  onset,  also,  is  often  not  met  with  in  cases  that  within  a 
few  hours  become  very  acute.  A  classical  attack  of  podagra,  at 
all  events  in  the  earlier  history  of  a  patient  goutily  disposed, 
is  not  infrequently  characterized  by  its  suddenness,  by  its  excru- 
ciating torture,  and  by  its  incidence  in  the  proximal  joint  of  one 
or  other  great-toe. 

Most  physicians  have  agreed  as  to  the  fact  that  in  most  cases 
the  four  cardinal  symptoms  of  inflammation  are  present,  and 
have  asserted  that  there  may,  thus,  be  found  tumor,  rubor,  color, 
et  dolor.  To  this  concise  definition  should  be  added  the  very 
frequent  occurrence  of  the  attack  in  the  early  hours  of  the 
morning. 

Statistics  in  proof  of  the  accuracy  of  the  above  statements  are 
not  wanting,1  and  the  experience  of  all  practitioners  daily  con- 
firms it. 

Exception  has  been  taken  to  the  assertion  that  a  noteworthy 
amount  of  inflammation  is  invariably  present,2  and  I  conceive 
that  such  an  objection  may  be  made  by  those  who  see  a  great 
deal  of  gouty  disease  ;  but  there  can  be  no  doubt  that  in  the 
majority  of  cases  of  acute,  regular,  and  localized  gout,  there  is 
present,  as  part  of  the  process,  an  obvious  measure  of  inflam- 
mation. 

In  an  early  fit  of  acute,  regular,  sthenic  gout,  the  patient,  who 

1  Scudamore,  op.  cit.,  3rd  edit.,  18 19,  p.  25. 

2  Vide  Gairdner  on  Gout,  2nd  edit.,  1851,  p.  108. 


248  CLINICAL   VARIETIES    OF  GOUT. 

may  have  previously  had  premonitions  of  an  attack — e.g.,  violent 
cramps  in  the  calves — usually  retires  to  rest  feeling  no  particular 
disturbance  of  health,  or  even  in  better  condition  than  is  his 
wont.  He  is  awakened  in  the  early  hours  of  the  morning  by 
violent  pain,  commonly  in  one  great  toe-joint.  A  slight  rigor 
sometimes  occurs  at  this  time.  The  pain  increases  to  positive 
agony,1  and  there  is  much  restlessness.  A  sense  of  extreme 
tension,  sometimes  with  throbbing,  is  experienced.  An  easy  posi- 
tion for  the  foot  is  sought  in  vain.  The  slightest  vibrations 
aggravate  the  pain,  so  that  the  sufferer  resents  even  the  move- 
ment of  the  bed-clothes,  or  the  tread  of  a  person  on  the  floor  of 
the  room.  The  pain  is  excruciating,  and  quite  peculiar  to  the 
earlier  processes  of  gouty  arthritis.  Nothing  at  all  like  it  occurs 
in  any  other  joint-disease.2  After  some  hours  a  measure  of  relief 
is  obtained,  sometimes  gradually,  or  quite  suddenly ;  perspiration 
occurs,  and  sleep  follows.  On  the  following  day  the  affected  joint 
is  found  swollen,  dusky  red  in  colour,  tense,  shining,  and  very 
sensitive  to  touch.  The  pain  is  apt  to  continue  with  more  or 
less  intensity  during  the  day,  and  to  rage  again  towards  evening. 
The  dorsal  veins  of  the  foot  are  observed  to  be  turgid.  The 
pulse  is  quickened,  80  to  100,  and  the  temperature  may  rise 
from  10 1  °  to  102°.  It  seldom  rises  higher.  I  have  several 
times  met  with  103°,  and  Garrod  has  once  found  it  104°. 

The  temperature  of  the  inflamed  joint,  though  feeling  preter- 
naturally  hot  to  the  hand,  may  be  below  normal.  I  have  found 
it  970,  while  that  in  the  mouth  at  the  same  time  was  100°,  and 
the  corresponding  unaffected  joint  was  96.3°.  In  another  in- 
stance, with  a  temperature  of  100.4°  in  the  mouth,  I  found  the 
joint  registered  only  95.6°.  These  temperatures  were  taken  by 
wrapping  up  the  joints  in  cotton-wool  and  inserting  the  thermo- 
meter for  twenty  minutes. 

The  symptoms  just  described  may  recur  for  several  days. 
(Edema  of  the  superjacent  integuments  sets  in  gradually,  and 
increases  up  to  the  fourth  or  fifth  day,  when  it  is  at  its  height, 
and  readily  allows  dimpling.      There   may  be  ecchymoses.     The 

1   "Tanquam  ossium  dislocatio." — Sydenham. 

"  "  The  pain  is  altogether  disproportionate  to  the  other  signs  of  inflammation,  and, 
even  more,  to  the  consequent  structural  changes  in  the  inflamed  part." — Paget. 

"The  inflammation  of  the  gout  is  very  different  from  the  adhesives  and  sup- 
purative in  its  sensation.  It  seldom  throbs  ;  it  is  a  pricking,  cutting,  and  darting 
pain,  besides  which  there  is  a  pain  which  feels  as  if  the  inflamed  parts  were  all 
moving,  and  in  that  motion  there  was  pain ;  therefore  the  action  which  is  the  cause 
of  the  pain  must  be  very  different,  and  is  most  probably  from  the  action  of  the 
vessels,  not  from  their  distension,  as  in  the  suppurative  inflammation." — Treatise 
on  the  Blood  and  Inflammation,  John  Hunter,  p.  266,  1794. 


ACUTE    GOUT.  249 

redness  also  passes  off  gradually  with  the  venous  turgescence. 
With  the  onset  of  oedema  comes  relief  to  pain.1  Severe  cramps 
in  the  calves  sometimes  occur.  There  is  commonly  a  furred 
tongue,  dirty  yellow  in  colour,  a  foul  breath,  much  thirst  and 
aversion  from  food.  There  may  be  a  bitter  taste  in  the  mouth. 
Hiccup  and  eructation  may  occur,  but  no  vomiting.  The  bowels 
are  usually  constipated ;  if  not,  there  may  be  pale  or  very  dark 
offensive  stools.  The  urine  presents  the  ordinary  febrile  char- 
acters, being  dark  in  colour,  scanty,  and  concentrated,  and  de- 
positing red  lithates  or  crystals  of  uric  acid.  There  may  be  a 
trace  of  albumen  lasting  through  the  attack.  The  cuticle  is 
next  observed  to  crack  and  degenerate,  this  process  being  accom- 
panied with  much  itching.  In  the  case  of  a  small  joint,  it  is  not 
possible  to  detect  effusion  within  it ;  but  in  the  case  of  the  knee 
or  ankle,  this  sign  is  evident. 

The  arthritis  having  passed  off,  the  patient  rapidly  recovers  his 
wonted  health,  and  feels  better  than  for  some  time  previously. 
Some  weakness  and  stiffness  remain  in  the  joint  for  a  few  days, 
and  recovery  is  established.  The  whole  attack  generally  runs  its 
course  within  a  week  or  ten  days. 

I  have  already  remarked  of  the  mode  of  onset  of  a  gouty 
paroxysm  that  this  peculiarity  stamps  a  nervous  character  upon 
the  malady,  and  allies  it  with  other  explosive  neurosal  disorders.2 

The  intense  painfulness  is  specific,  and  pertains,  as  I  have 
stated,  to  no  other  form  of  arthritis.  Scudamore  noted  that  there 
was  most  sense  of  throbbing  when  the  great-toe  was  involved  ;  that 
there  was  more  sense  of  weight  and  loss  of  power  when  the  tarsus 
was  the  seat  of  the  attack,  and  that  the  feeling  of  tightness  was 
most  urgent  when  the  elbow  and  carpus  were  implicated.      Gene- 

1  Attention  has  been  pointedly  directed  to  the  occurrence  of  cedema  as  part  of  the 
inflammatory  process.  It  is  commonly  present,  but  I  cannot  agree  with  those 
observers  who  regard  it  as  absolutely  pathognomonic  of  true  gout.  A  measure 
of  cedema  is  always  present  in  acute  inflammation,  and  constitutes  the  outermost 
rino-  or  zone  of  simple  (serous)  excitement,  as  the  late  Professor  Miller,  of  Edin- 
burgh, termed  it.  A  slight  degree  of  such  swelling  is  certainly  found  in  connection 
with  rheumatic  inflammation,  and  in  other  forms  of  arthritis,  albeit  it  is  often  a 
marked  feature  in  acute  attacks  of  gout.  In  chronic  forms  of  both  gouty  and  rheu- 
matic inflammation  cedema  is  not  recognized.  The  desquamation  of  the  cuticle, 
which  very  commonly  occurs  after  acute  gouty  inflammation,  is  certainly  peculiar 
and  characteristic.  In  many  instances  this  process  is,  I  believe,  at  least  encouraged 
by  the  various  applications  which  are  used  to  mitigate  the  pain  during  an  attack, 
and  the  degree  of  previous  inflammatory  distension,  as  in  the  case  of  erysipelas,  may 
also  determine  the  amount  of  it.  Trousseau  aptly  likened  the  appearance  of  a  part 
recently  affected  with  true  gout  to  the  outer  pellicle  of  an  onion. 

2  Vide  p.  48,  chap.  iii.  The  time  at  which  seizures  commonly  occur  is  in  the  early 
hours  of  morning.  At  this  period  there  is  the  greatest  cessation  of  activity  of  the 
nervous  system,  predisposing  to  sleep. 


250  CLINICAL   VARIETIES   OF   GOUT. 

rally,  it  may  be  affirmed  that  gout  of  the  lower  extremities  is  more 
insupportable  than  that  of  the  upper  limbs,  and  an  experienced 
sufferer  declared  to  Scudamore  that  the  two  most  painful  parts  to 
be  involved  were  the  ham-strings  and  ligament  of  the  patella  ;  and 
this  I  can  readily  believe,  since  it  is  very  difficult  to  prevent 
motion  in  these  structures.  Gout  in  the  nape  of  the  neck  is  also 
extremely  painful.  Sydenham  truly  noted  the  constant  tendency 
of  the  pain  to  increase  at  night  and  remit  in  the  morning. 

The  special  implication  of  a  great  toe-joint,  especially  in  early 
attacks  of  gout,  has  long  attracted  attention,  and  been  much  dis- 
cussed. The  most  satisfactory  explanations  to  my  mind  relate  to 
the  inordinate  exposure  of  these  joints  to  hard  work,  compression, 
and  injuries,  whereby  there  is  always  tendency  to  damage  of  the 
integrity  of  their  component  structures.  The  entire  weight  of 
the  body  is  borne  by  these  joints.  In  healthy  persons,  as  our 
observations  at  St.  Bartholomew's  amply  prove,  it  is  common  to 
find  erosion  of  the  investing  cartilages,  more  especially  about 
the  centre  of  the  cup  of  the  first  phalanx.  Such  a  part  is  there- 
fore predisposed  to  uratic  infiltration  and  deposit  as  a  locus  minoris 
rcsistentice.  Next  to  the  great  toe  the  knee-joints  are  most  apt 
to  suffer  erosions,  and,  so,  are  similarly  predisposed  to  attacks  of 
uratic  arthritis. 

I  have  already  stated  that  too  much  blame  must  not  be  attached 
to  tight  boots,  since  gout  has  from  all  time  shown  predilection  for 
the  great  toe-joints.  Improperly  fitting  boots,  however,  may  very 
well  cause  damage  to  these  structures. 

It  must,  however,  be  stated  that  attacks  of  acute  articular  gout 
are  not  always  violent  or  paroxysmal,  even  in  the  first  instance. 
They  may  supervene  gradually,  becoming,  however,  fairly  "  classi- 
cal "  at  last.  Whether  such  shall,  or  shall  not,  be  the  character 
of  the  attack  depends  probably  on  the  degree  of  goutiness  present 
at  any  given  time,  and  no  less  on  the  special  proclivity  of  the 
individual  and  the  determinant  of  the  fit. 

Many  attacks  begin  during  the  day,  and  this  is  perhaps  more 
often  the  case  after  the  disorder  is  fully  established. 

After  a  primary,  regular  fit,  some  time  may  elapse  before  a 
second  one,  much  depending  upon  the  degree  of  heredity,  the 
treatment,  and  the  fortitude  of  the  individual  in  altering  his  habit 
of  life. 

Oases  are  met  with  in  which  one  or  two  attacks  are  all  that 
ever  occur  in  a  lifetime.  It  is  more  common,  however,  once  the 
gouty  habit  is  declared,  for  renewed  paroxysms  to  supervene,  and 
these  tend  to  recur  not  only  in  the  previously-affected  localities, 


ACUTE   GOUT.  25  I 

but  to  involve  other  joints  centripetal  ly,  seizing  on  the  tarsus, 
ankles,  knees,  hands,  and  elbows.1  The  hip-joint  and  shoulder 
are  singularly  immune,  but  not  altogether  exempt  from  uratic 
arthritis,  herein  presenting  a  noteworthy  contrast  to  the  course  of 
chronic  rheumatic  arthritis.  In  some  cases,  fresh  attacks  super- 
vene with  very  brief  intervals,  and  the  general  health  is  seriously 
impaired.  Primary  attacks  are  not  uncommon  in  other  than  the 
great  toe-joints,  the  knee  being  very  prone  thus  to  suffer,  likewise 
the  tarsus  and  ankles.  In  such  cases  this  departure  from  the 
common  habit  of  the  disease  may  be  sometimes  explained  by 
previous  injuries  or  strains  of  the  parts  affected,  or  by  certain 
occupations  which  lead  to  over-use  of  and  damage  in  joints. 

An  attack  of  acute  gout  which  passes  off  completely  in  a  few 
days,  probably  leaves  very  little  permanent  change  behind  it. 
Acute  rheumatism  is  known  to  leave  none.  We  are  here  in  face 
of  the  fact  that  each  attack,  so  far  as  is  known,  leaves  its  trace 
in  the  form  of  some  amount  of  uratic  deposit  on  the  articular 
cartilage  or  other  tissue  of  the  joint.  Naturally  our  knowledge 
is,  and  must  be,  very  limited  as  to  this.  There  is  reason  to 
believe  that  acute  attacks  sometimes  supervene  in  parts  which 
have  long  been  the  seat  of  quiet  deposit,  with  or  without  subacute 
inflammatory  reaction.  In  such  a  case  there  would  be  post-mortem 
evidence  of  chronic  arthritis,  with  more  or  less  uratic  deposit, 
and  the  clinical  symptoms  of  the  case  would  alone  have  given 
token  of  any  disturbances  prior  to  the  acute  attack.  In  such 
cases  there  may  have  only  been  occasional  twinges  of  pain  or  of 
uneasiness  in  the  joint.  Sometimes,  actual  deformity  has  occurred 
before  any  acute  attack  supervenes,  due  to  ostitis  and  some  ero- 
sion or  damage  to  the  cartilages.  These  are  really  examples  of 
chronic  gout  with  acute  inflammatory  exacerbations. 

I  am  here  discussing  the  permanent  coarse  changes  due  to 
acute  attacks,  and  for  these  we  must  look  alone  to  the  joints,  for 
we  cannot  expect  to  find  elsewhere  any  traces  of  the  malady  in 
its  early  stages. 

Early  attacks  may  leave  behind  them  permanent  crippling  and 
deformity.  True  ankylosis  may  occur,  and  this  is  peculiar  to 
gouty  arthritis.  Bony  union — synostosis — is  never  met  with  in 
rheumatic  disease.  I  have  twice  seen  complete  synostosis  of  the 
first  metatarsal  bone  with  the  phalanx.  "  Lipping  "  of  the  edges 
of  the  joint  may  occur,  giving  rise  to  bunion,  and  to  extreme  deflec- 
tion of  the  digit  to  the  outer  side  of  the  foot. 

1  "  After  it  has  attacked  each  foot,  the  fits  become  irregular,  both  as  to  the  time  of 
their  accession  or  duration." — Sydenham. 


252  CLINICAL    VARIETIES    OF    GOUT. 

It  is  noteworthy  that  repeated  attacks  of  true  gout  may  in 
some  cases  leave  no  traces  behind  in  the  form  of  uratic  deposit. 
I  have  recorded  one  such  instance.1  The  case  was  of  great  interest 
because  of  a  rare  form  of  cardiac  disease  in  which  reflux  occurred 
through  the  pulmonary  valves.  It  was  that  of  a  man,  set.  forty- 
nine,  who  had  had  many  attacks  of  gout  in  both  great  toes,  some 
under  my  own  observation.  At  the  autopsy  no  deposits  were 
found  in  either  toe-joint. 

It  is  rare  for  gouty  fits  to  involve  more  than  one  or  two  joints 
in  its  earlier  periods,  but  cases  occur  in  which  many  articulations 
are  seized  (polyarthritis  uratica).  The  diagnosis  then  becomes 
somewhat  difficult,  since  such  a  manifestation  resembles  acute 
rheumatism.  The  history  of  the  illness,  the  personal  history,  the 
age  of  the  patient,  the  temperature,  the  absence  of  sour  sweats 
and  of  cardiac  implication  should  avail  to  render  the  diagnosis 
almost  certain.  There  is  no  incompatibility  between  true  rheu- 
matism and  true  gout  in  the  same  individual,  and  the  previous 
occurrence  of  the  former  may  possibly  tend  to  the  establishment 
at  a  later  period  of  gouty  polyarthritis ;  but  such  cases  are  cer- 
tainly not  often  encountered  in  practice.  The  existence  of  tophi 
anywhere  should  promptly  throw  light  on  them. 

Garrod's  blister-serum  test  may  be  had  recourse  to  in  any  un- 
certainty. I  have  met  with  two  or  three  of  these  cases.  They  do 
not  respond  promptly,  if  at  all,  to  the  influence  of  sodium  salicy- 
late, colchicum  being  much  more  efficacious,  and,  thus,  indicative 
of  their  true  nature. 

Repeated  regular  attacks  may  occur,  and  no  indications  of  uratic 
deposit  be  met  with  in  any  part,  even  after  many  years.  Patients 
vary  infinitely  in  this  respect. 

Where  there  is  great  tendency  to  formation  of  tophi  around 
joints  or  in  the  ears,  the  encrustation  may  proceed  to  great  excess 
without  painful  paroxysms  bearing  any  proportion  to  the  depo- 
sition. There  is,  in  fact,  a  special  clinical  type  of  gout  in  which 
this  tendency  predominates,  the  upper  extremities  being  by  far 
the  most  involved,  and  the  deposit  proceeding,  as  it  were,  quietly 
but  ruthlessly  towards  the  most  hopeless  crippling  of  the  parts, 
the  fingers  assuming  the  "  parsnip-type  "  and  becoming  enormous. 

An  acute  attack  may  not  pass  off  completely  in  a  few  days. 
After  repeated  attacks  there  is  tendency  sometimes  for  gout  to 
linger  for  weeks,  and  even  months,  in  the  part.  This  is  mostly 
seen  in  older  persons  with  enfeebled  constitutions,  but  it  may  be 
met  with  in  patients  under  fifty  years  of  age,  still  robust.  Syden- 
1  Clin.  Soc.  Trans.,  vol.  xxi.  p.  18,  1888. 


ACUTE    GOUT.  253 

ham  considered  such  an  attack  to  represent  a  series  of  minor  fits 
rather  than  a  prolonged  paroxysm. 

Acute  gout  in  the  foot  is  probably  the  least  harmful  form  in  which 
the  disease  occurs,  because  this  indicates  the  most  regular  course. 

The  mental  faculties  remain  clear,  as  a  rule,  during  the  pro- 
gress of  an  acute  fit,  and  sometimes  there  is  full  capacity  for 
intellectual  labour  during  the  paroxysm.1  The  influence  of  the 
mind  and  of  a  strong  will  in  "  fighting  down "  the  gout  is  in 
some  instances  very  remarkable,  so  much  so,  that  the  usual  pro- 
gress of  an  attack  appears  to  be  modified  or  even  arrested. 

An  indication  of  past  attacks  is  sometimes  met  with  in  the 
form  of  transverse  depressions  on  the  nails  of  the  toes,  as  de- 
scribed originally  by  M.  Beau,2  who  noted  their  occurrence  after 
acute  general  illnesses  as  well  as  after  severe  local  disturbances.  As 
a  complete  nail  takes  six  mouths  to  grow,  the  site  of  these  depres- 
sions affords  a  fairly  accurate  indication  of  the  date  of  the  past 
attack. 

W.  Gairdner  believed  that  the  left  limbs  were  more  often 
affected  than  the  right,  and  he  found  metastasis  more  common 
from  the  right  to  the  left  limbs.  Laycock  and  Gull  taught  that 
all  actions,  both  healthy  and  morbid,  were  less  energetic  on  the 
left  than  on  the  right  side  of  the  body. 

Scudamore,  Garrod,  and  Braun,  of  Wiesbaden,  have  proved  by 
their  statistics  the  very  marked  predilection  for  the  great  toe- 
joints  in  early  attacks.  These  are  the  parts  commonly  affected 
first  in  hereditary  gout,  and  it  is  rare  for  the  upper  extremities 
to  be  the  seats  of  primary  attacks. 

Acute  and  Regular  Gout  less  common  than  formerly. 

It  is  certain  that  instances  of  acute  gout — cases,  that  is,  of 
classical  podagra — are  less  frequently  met  with  than  was  the  case 
in  Sydenham's  time,  or  even  a  century  ago..  An  inquiry  into  the 
cause  of  this  infrequency  must  yield  assistance  in  studying  the 
astiology  of  gout,  and  a  ready  explanation  is  at  ouce  afforded  by 
the  marked  change  in  dietetic  habits  now  prevalent.  The  gross 
over-eating  and  disgusting  alcoholic  intemperance  which  were 
common  amongst  the  wealthier  classes  of  society  at  the  time 
referred  to,  happily,  no  longer  exist. 

It  may  also  be  regarded  as  certain  that  the  excesses  of  the  last 
century  have  left  an  ample  legacy  of  gouty  disease  in  this  country, 

1  Vide  chap.  xxi. 

2  M.  Beau  pointed  these  out  to  me  in  his  wards  in  the  Hotel-Dieu  in  1862. 


2  54  CLINICAL   VARIETIES    OF    GOUT. 

but  it  is  highly  probable  that  the  amended  dietetic  habits  of  more 
recent  times,  and  in  particular  the  diminished  consumption  of  the 
strong  wines  of  Spain,  Portugal,  and  Madeira,  have  much  to  do 
with  the  comparative  infrequency  of  sthenic  gout  at  the  present 
time.  Sir  George  Burrows  informed  me  twenty-six  years  ago 
that  he  then  saw  fewer  cases  of  acute  gout  than  he  was  accustomed 
to  see  in  his  earlier  practice.  Amongst  subsidiary  causes  for  the 
diminution  of  acute  gouty  disease,  may  probably  be  reckoned  the 
better  ventilation  and  hygiene  of  modern  times,  and  the  great 
increase  in  the  consumption  of  water,  especially  in  the  forms  of 
various  mineral  waters.  The  increased  use  of  the  lighter  and 
thoroughly  fermented  vintages  of  the  Medoc,  in  place  of  heavier 
and  incompletely  fermented  wines,  and  of  strong  ales,  together 
with  the  results  of  the  several  earnest  crusades  against  alcoholic 
intemperance,  may  also  be  credited  with  noteworthy  results  in 
this  direction. 

Although  there  may  be  less  acute  and  typical  gouty  disease 
than  formerly,  the  opinion  gains  ground  that  many  of  the  mani- 
festations of  gout  at  the  present  time  are  modified  by  inheritance 
and  change  in  habits,  so  as  to  be  less  easily  recognized.  Thus, 
there  are  now  met  with  cases  of  incomplete  or  imperfect  gout,  as 
well  as  a  variety  of  disorders,  which,  by  reason  of  their  constant 
association  with  gouty  inheritance,  mode  of  onset,  response  to 
specific  treatment,  and  their  general  habit,  are  fairly  to  be 
reckoned  as  the  outcome  of  gout  and  as  indications  of  it. 

That  gouty  diseases  and  manifestations  are  very  common  at 
the  present  time  cannot  be  doubted,  and  when  all  allowance  is 
made  for  the  dicta  of,  so-called,  "  fashionable  physicians  "  respecting 
the  great  prevalence  of  gout,  it  must  be  affirmed  that  many  of  the 
ailments  of  the  affluent  classes  in  this  country  are  modified  by, 
and  often  dependent  upon  it. 

Chronic  Gout. 

"We  do  not  learn  chronic  disease  from  seeing  it  as  a  whole,  as  it  passes  through 
all  its  stages  in  the  same  individual  men  and  women.  Being  an  affair  not  of  days  or 
weeks,  but  of  months,  and  many  months,  and  oftener  of  years,  and  oftener  still  of 
many  years,  we  are  indeed  very  seldom  present  as  eye-witnesses  of  it  from  first  to  last. 
Thus  our  knowledge  of  it  is  not  drawn  from  single  and  complete  histories,  but  put 
together  piecemeal  from  numerous  imperfect  ones.  .  .  .  The  most  useful  and  per- 
haps only  just  representation  that  can  be  made  of  chronic  disease  is  not  in  the  way 
of  description,  but  of  commentary." — Peter  Mere  Latham,  op.  cit.,  p.  358. 

It  is  not  easy  to  determine  precisely  when  the  acute  form  of 
the  disorder  passes  into  the  chronic  variety.     The  latter  condition 


CHRONIC    GOUT.  255 

represents  a  stage  when  acute  paroxysmal  attacks  have  become 
frequent  and  well-nigh  continuous,  complete  recovery  in  the  parts 
affected,  and  of  the  system  generally,  not  being  attained. 

Recurring  fits  of  lesser  intensity  gradually  lead  up  to  the  state 
recognized  as  chronic  gout.  If  the  first  fit  occurs  late  in  life, 
there  may  be  long  intervals.  The  latter  may  also  occur  in  early 
life ;  but  where  the  first  attacks  are  developed  before  forty  years 
of  age,  the  disease  is  very  apt  to  recur  soon,  and  to  manifest  an 
atonic  form  with  various  tissue-degenerations.  Such  examples  are 
significant  of  strong  hereditary  tendency  or  of  feeble  constitution, 
or,  indeed,  of  both. 

The  influence  of  the  disease  is  in  direct  relation  to  the  general 
vigour  of  nutrition  and  the  force  of  tissue-resistance.  Hence,  old 
persons  may  be  met  with  of  originally  powerful  constitutions  who 
may  have  been  gouty  for  many  years,  and  yet  have  resisted  the 
degenerations  so  commonly  associated  with  the  disease,  and,  in 
particular,  show  no  signs  of  uratic  deposit  at  any  point.  They 
are,  in  fact,  little  the  worse  for  the  gout,  and  reach  a  ripe  age. 
In  persons  of  less  vigour,  the  same  gravity  of  the  disease  will 
suffice  to  induce  decided  gouty  cachexia.  Good  constitutions  may, 
however,  be  ruined  and  yield  to  prolonged  excesses  and  indul- 
gences, whence,  even  in  early  life,  such  persons  are  no  better  than 
the  heritors  of  an  originally  frail  habit  of  body. 

In  chronic  gout  the  local  processes  linger  and  fail  to  leave  the 
joints.  Effusions,  enlargements,  stiffness,  and  crippling  gradually 
supervene.  Slight  paroxysms  are  readily  provoked,  and  add  little 
to  the  abiding  discomfort.  Several  joints  become  thus  implicated, 
and  the  patient  grows  more  and  more  infirm.  The  gouty  habit 
is  pronounced,  and  manifested  by  many  untoward  symptoms. 
One  ailment  sets  in  after  another,  now  of  the  digestive  organs, 
now  of  the  heart,  or  of  the  kidneys.  Thus  come  into  prominence 
many  of  the  troubles  recognized  as  incomplete  gout.  As  has 
been  said,  "  The  patient  now  no  longer  has  the  gout,  but  the 
gout  has  the  patient."  The  natural  look  of  health  departs,  and 
the  face  becomes  sallow  or  pasty,  the  circulation  is  feeble,  and 
a  general  aging  is  manifest.  Serous  circulation  is  slow,  whence 
tendency  to  slight  oedema  of  eyelids  and  extremities,  although 
the  kidneys  may  not  yet  be  seriously  involved.  The  tendency 
to  various  discomforts  and  pains  indicates  a  disposition  towards 
wandering  or  retrocedent  gout,  and  when  these  rapidly  change 
their  place,  the  term  "  flying  gout  "  is  sometimes  applied.1 

1  As  pointed  out  by  my  friend  Dr.  Wynne  Foot,   of  Dublin,  the  term  "flying 
gout "  appears  to  have  been  first  used  by  Mrs.  Hunter,  wife  of  John  Hunter,  in  a 


256  CLINICAL   VARIETIES   OF   GOUT. 

In  treating  of  chronic  gout,  I  shall  describe  two  main  varieties, 
which  deserve  to  be  treated  separately,  because  they  fairly  repre- 
sent two  clinical  types.  I  take  first,  therefore,  (A)  the  tophaceous 
variety,  and  (B)  the  deforming  variety.  Both  forms  may,  and  do, 
occur  together,  but  in  practice  the  two  may  best  be  separately 
regarded. 

A.  Tophaceous  Variety. — It  is  in  the  chronic  form  of  the  dis- 
ease that  tophi  are  most  apt  to  be  formed  in  various  situations.1 
This  "tartar  of  the  blood  "  or  "  gravel  of  the  skin"  mostly  appears 
in  the  vicinity  of  affected  joints  or  in  the  integument  of  the 
ears.  It  is  presumably  present  in  the  encrusting  cartilages  of  the 
joints,  or  in  their  synovia  or  ligaments.  In  the  latter  case  it 
may  be  felt  if  not  seen,  and  in  extreme  degrees  of  this  deposition, 
hardly  any  part  of  the  integument  may  escape  it.  The  nature  of 
this  is  now  fully  understood  and  recognized  by  appropriate  tests. 
The  only  morbid  appearances  at  all  resembling  tophi  are  small 
sebaceous  tumours,  such  as  milium,  found  on  the  face  near  the 
eyelids,  or  larger  ones  which  may  occur  on  the  neck,  chest,  upper 
arms,  or  scrotum.  Deposits  on  the  eyelids  may  somewhat  simulate 
patches  of  xanthoma.  The  microscope  will  clear  up  any  dubiety, 
or  failing  this,  the  employment  of  the  murexide  test.2 

The  laity  never  fail  to  recognize  this  form  of  the  disease,  which 
they  term  "  chalky  gout,"  and  if  history  be  given  of  ancestors  or 

letter  to  Dr.  Edward  .Tenner  about  her  husband,  dated  Bath,  September  13,  17S5. 
She  mentions  that  "he  has  been  tormented  with  a  flying  gout  since  last  March." — 
Works  of  John  Hunter,  edited  by  James  F.  Falmer,  vol.  i.  p.  96,  1835. 

It  is  of  interest  to  note  that  this  great  man  was  a  sufferer  from  gouty  ailments. 
At  the  age  of  forty-six  he  had  attacks  of  spasm  in  the  region  of  the  pylorus,  and  of 
failure  of  cardiac  action.  At  forty-nine  he  had  severe  vertigo  for  ten  days,  being 
unable  to  raise  his  head  from  his  pillow.  Jenner,  who  saw  him  at  Bath,  made  the 
diagnosis  of  angina  pectoris,  and  wrote  his  opinion  to  Heberden.*  At  fifty-seven 
he  had  slight  symptoms  of  regular  gout,  which  were  followed  by  irregular  spasms  of 
the  face,  arm,  stomach,  and  heart — "flying  gout."  At  sixty-one  he  had  attacks  of 
amnesia,  lasting  half  an  hour,  coming  on  suddenly.  Afterwards  he  was  subject  to 
angina  pectoris  on  exertion  or  emotion.  He  was  always  irascible  and  explosive  in 
temper.  His  death  was,  as  is  well  known,  sudden,  in  an  anginal  paroxysm,  pro- 
voked by  deep  emotion,  at  the  age  of  sixty-seven.  His  aorta,  coronary,  carotid,  and 
cerebral  arteries  were  calcified,  aortic  and  mitral  valves  thickened,  heart-structure 
"  pale  and  loose."  With  the  knowledge  of  to-day,  it  is  easy  to  read  the  pathological 
lessons  of  his  case.     He  was  a  temperate  man. 

1  "  Abeuns  in  cretam,  calcemve." — Boerkaavc's  Aphorisms,  1261. 

2  "  Callosities  also  form  in  the  joints  :  at  first  they  resemble  abscesses,  but  after- 
wards they  get  more  condensed,  and  the  humour  being  condensed,  is  difficult  to  dis- 
solve ;  at  last  they  are  converted  into  hard  white  tophi  (irQpoi  areppol  Xevnol),  and 
over  the  whole  there  are  small  tumours  like  vari  and  larger,  but  the  humour  is  thick, 
white,  and  like  hailstones." — Aretceus,  ITepi  'ApOpinSos  (second  century  A.D.). 

*  He,  however,  withheld  this  letter. 


TOPHACEOUS   GOUT.  257 

relatives  thus  affected,  there  need  be  no  hesitation  in  pronouncing 
for  true  gout  amongst  them,  and  for  the  probable  gouty  nature 
of  such  arthritic  ailments  as  may  be  complained  of  by  the  patients 
under  examination. 

With  the  presence  of  tophaceous  deposit  is  associated  a  pecu- 
liar soft  and  satin-like  condition  of  the  skin.  The  integument 
of  a  labouring  man  may,  thus,  come  to  resemble  in  texture  that 
of  a  delicately-nurtured  woman,  the  skin  being  very  smooth  and 
glossy.  In  the  vicinity  of  tophi  there  is  usually  a  dusk}'  pink 
or  red  colour  of  integument,  through  which  subjacent  uratic 
deposits  may  glisten,  a  little  pressure  being  sufficient  to  make 
the  latter  plainly  visible,  even  where  they  are  situated  somewhat 
deeply.1 

In  chronic  gout  the  skin  of  the  limbs  may  become  very  soft 
without  the  occurrence  of  tophi,  or  when  these  exist  only  in  the 
ears.  In  the  latter  situation  tophi  may  sometimes  be  well-demon- 
strated by  holding  a  light  behind  the  auricle,  when  deposits  are 
disclosed  as  black  spots,  which  may  be  hardly  recognizable  by 
reflected  light.  When  large  accumulations  of  urates  have  been 
formed  around  joints,  the  integuments  become  so  stretched  and 
attenuated  that  they  give  way,  and  afford  exit  to  a  creamy  pul- 
taceous  fluid,  consisting  almost  wholly  of  densely-packed  crystals 
of  sodium  urate,  but  also  of  calcic  urate  and  phosphate,  sodium 
chloride,  and  animal  matter.  Masses  of  urates  may  be  discharged 
from  time  to  time,  and  after  a  free  evacuation  there  may  be  a  lull, 
the  broken  surface  presenting  the  aspect  of  a  flabby  or  indolently 
granulating  ulcer,  with  serous  or  slightly  opalescent  fluid  exuding 
from  it.  Deep  in  the  ulcer  may  be  seen  other  more  solid  deposits 
in  course  of  breaking  down  or  of  extrusion.  As  a  result  of  such 
discharge,  a  joint  may  come  to  assume  a  more  shapely  appearance, 
and  the  ulcer  heals  up.  Meantime,  other  deposits  may  break  down 
elsewhere  in  similar  fashion.  The  size  attained  by  these  masses  is 
sometimes  very  great.  In  Fig.  1 6,  p.  84,  I  have  depicted  the  most 
extreme  instance  that  I  have  met  with.  Some  of  the  fingers 
were  as  large  as  turkey's  eggs. 

1  Concerning  this  variety  of  gout  John  Hunter  wrote  as  follows  : — "  Chalk  is 
not  necessarily  an  effect  of  the  gouty  inflammation,  for  in  a  gouty  habit  we  have 
chalk  formed  where  there  never  had  been  any  gouty  inflammation.  .  .  .  The  chalk 
shall  remain  for  years  without  producing  inflammation,  and  seldom  produces  it  at 
all,  but  from  quantity.  And  when  the  interior  surfaces  are  exposed,  they  hardly 
take  on  common  inflammation  and  suppuration,  healing  more  readily  than  a  sore  of 
the  same  magnitude  from  any  other  cause  ;  even  a  joint  shall  be  exposed,  yet  common 
inflammation  shall  not  come  on,  nor  shall  it  suppurate,  only  a  watery  fluid  shall  come 
out,  bringing  with  it  the  chalk  occasionally,  and  it  shall  heal  up  kindly." — Op.  cit., 
p.  268. 

R 


258  CLINICAL   VARIETIES    OF    GOUT. 

In  Fig.  2 1  is  depicted  a  less  grave  form  of  tophaceous  arthritis, 
which,  however,  induced  much  crippling  of  the  fingers. 


Fig.  21. 


Uratic  deposits  are  not,  however,  always  painless  during  their 
formation.  After  acute  attacks  of  gout  have  passed  off,  there 
may  follow  renewed  pain  in  the  neighbourhood  of  the  joint,  and 
later  there  is  discovered  a  nodular  or  a  soft  swelling.  In  the 
latter  case  there  may  be  fluctuation,  indicating  a  liquid  collection 
of  urates.  This  should  never  be  opened.  In  a  few  weeks  this 
tumour  tends  to  indurate  and  grow  more  compact,  and  a  so-called 
"  chalky  "  concretion  is  established.  With  renewed  accessions  of 
gouty  attacks  fresh  deposits  may  be  laid  down.  When  these  are 
small  and  flattened,  they  do  not  tend  to  cause  ulceration,  and 
remain  as  streaks  or  plates  scattered  in  the  integuments. 

Deposits  in  the  vicinity  of  joints  may  disappear  during  renewed 
attacks  of  arthritis,  and  others  form  elsewhere  around  the  joint. 
Bursae  over  joints  are  common  sites  for  deposit.  That  over  the 
olecranon  may  become  the  site  of  a  large  fluctuating  tumour  full 
of  synovial  fluid  impregnated  with  urates,  which  may  in  time 
become  firm  and  compact.  Those  over  the  fingers  and  the  patellae 
are  frequently  involved.  Abarticular  tophi  are  not,  as  a  rule, 
accompanied  by   any  painful  process.      I  have  seen  many  cases 


TOPHACEOUS   GOUT.  259 

illustrating  this  fact,  of  which  the  commonest  example  is  that 
supplied  by  deposits  in  the  ears.1  The  following  was  a  very- 
remarkable  instance  : — 

J.  W.,  set.  fifty-eight,  a  retired  lighterman,  robust-looking  and  of  large  frame,  came 
to  the  Hospital  to  my  colleague,  Mr.  Butlin,  on  account  of  numerous  small  tumours 
of  the  scrotum.  There  were  about  five-and-twenty  of  them,  situated  chiefly  at  the 
sides  of  the  purse,  the  skin  of  which  was  melasmic  as  seen  in  advanced  Addison's 
disease.  In  colour  the  tumours  contrasted  markedly  with  the  dark  integument,  being 
bright  pink  for  the  most  part,  with,  in  some  instances,  whitish  specks  on  their  sur- 
face. They  somewhat  resembled  a  large  crop  of  sebaceous  mollusca,  but  had  no 
umbilicated  hilirm.  They  proved  to  be  tophaceous,  crystals  of  sodium  urate  being 
found  in  the  milky  pap  which  was  forced  through  a  puncture  made  in  one  of  them. 
Fatty  matters  and  cholesterine  crystals  were  also  found.  The  murexide  test  was 
also  satisfactorily  obtained. 

The  history  was,  that  these  tumours  had  begun  to  form  at  the  age  of  nineteen,  and 
had  since  grown,  some  having  discharged  and  disappeared.  Attacks  of  frank  gout 
had  been  frequent,  not  very  painful,  beginning  in  the  right  great-toe,  then  in  the 
left,  forty  or  fifty  such  fits  having  been  experienced.  The  knees  had  suffered,  and 
the  metacarpophalangeal  and  phalangeal  joints  of  the  right  fore  and  middle  fingers. 
No  distortions  existed  in  any  joints,  and  no  tophi  were  found  elsewhere  than  on  the 
scrotum.  There  was  optic  neuritis  in  the  right  eye,  and  a  large  detachment  of  the 
retina  at  lower  part.  In  the  left  eye  were  patches  of  choroidal  atrophy  with  myopic 
crescent. 

This  man  had  drunk  all  kinds  of  liquors,  but  not,  according  to 
his  account,  very  intemperately.  He  knew  of  no  history  of  gout 
in  his  family.  His  mother,  he  believed,  had  had  rheumatic  fever. 
A  coloured  drawing  was  made  for  the  Museum. 

It  is  not  easy  to  account  for  the  occurrence  of  so  many  tophi 
solely  in  a  part  for  which  gout  has  no  special  predilection,  and 
which  is  commonly  endowed  with  a  vigorous  circulation.  I 
showed  this  patient  at  the  Clinical  Society,  in  February  1889. 
It  was  suggested  by  some  members  that  these  growths  had 
originally  been  of  the  nature  of  molluscum  fibrosum.  Such 
a  case  well-illustrates  the  fact  that  tophaceous  gout  runs  a 
different  course  from  the  more  painful  deforming  variety  of 
the  disease.  Tophi  sometimes  precede  by  some  years,  as  iu 
the  foregoing  case,  the  development  of  gouty  attacks  in  joints. 
The  same  is  true,  also,  of  auricular  tophi.  In  persons  suffering 
from  frail  health  (gouty  cachexia),  abscesses  may  form  around 
the  deposits,  and  give  rise  to  discharge  of  pus  and  urates,  and 
whenever  ulceration  and  flow  of  tophaceous  matter  occurs,  it  is 
rare  to  meet  with  paroxysmal  attacks  anywhere  in  the  body. 
With  the  cessation  of  the  discharge  renewed  fits  may  supervene. 
Cases  of  extreme  tophaceous  deposit  may  be  met  with  in  persons 
who  have  always  abstained  from  alcohol.      Sir  William  Gull  has 

1  Sometimes  auricular  tophi  are  a  little  painful  at  an  early  stage. 


260  CLINICAL    VAEIETIES    OF   GOUT. 

told  me  of  one   such  case,  which  occurred  in  the  son  of  a  very 
gouty  father  who  also  was  a  total  abstainer  from  alcohol. 

Tophaceous  gout  is  commonly  seen  in  the  male  sex,  but  well- 
marked  examples  have  come  under  my  notice  in  women.  Trau- 
matism sometimes  determines  the  localization  of  a  deposit,  but 
most  instances  cannot  be  so  traced. 

As  pointed  out  by  Garrod,  the  rule  commonly  holds  good  that 
where  extraordinary  tophaceous  deposition  prevails,  the  kidneys 
may  be  regarded  as  unsound  and  in  progress  of  contraction. 
Such  cases  are  more  correctly  included  in  the  category  of  gouty 
cachexia,  under  which  head  I  shall  more  particularly  refer  to  them. 
It  is,  however,  not  very  uncommon  to  meet  with  tophi  in  the  ears 
of  patients  who  enjoy  fairly  robust  health,  and  are  capable  of 
mental  and  bodily  activities.  It  is  not  within  my  experience 
that  any  morbid  growths  in  gouty  subjects,  such  as  innocent 
tumours  or  scars,  ever  become  infiltrated  with  urates.  When  I 
exhibited  the  patient  with  scrotal  tophi  at  the  Clinical  Society, 
several  members  reported  that  they  had  seen  similar  cases,  and 
the  question  was  raised  as  to  these  having  been  originally  mollus- 
cous tumours  which  became  subsequently  infiltrated.  If  this  was 
really  the  case,  the  occurrence  must  be  of  extreme  rarity. 

B.  Chronic  Deforming"  Gout  {Arthritis  deformans  uratica). — 
With,  or  without,  much  uratic  deposit  may  occur  various  defor- 
mities in  the  affected  joints  in  chronic  gout.  Many  of  these  I 
have  already  described  in  the  chapter  on  the  morbid  anatomy  of 
articular  gout,  and  they  have  long  afforded  matter  for  discussion 
respecting  the  rheumatic  element  which  some  authorities  allege 
to  be  mixed  with  gout  in  such  instances.  I  believe  that,  for  the 
majority  of  articular  deformities  and  distortions  met  with  in 
uratic  arthritis,  gout  is  solely  responsible,  and  that  many  of  the 
changes  thus  wrought  are  similar  to,  but  not  the  same  as,  those 
induced  by  rheumatic  disease.  The  evidence  as  to  causation  is 
not  afforded  by  a  study  alone  of  the  results  of  either  disease. 

The  most  obvious  changes  relate  to  enlargement  and  distortion 
of  the  component  structures  of  the  affected  joints.  The  degree 
in  which  slowly  progressive  ostitis,  chondritis,  and  induration  of 
synovial  membrane  occur  is  dependent  not  only  on  the  severity 
of  the  irritant  gouty  process,  but  also  on  the  textural  peculiarities 
and  special  vulnerability  of  the  individual  affected.  Hence,  the 
explanation  of  the  apparent  paradox  of  slight  or  no  articular 
deformity  in  cases  of  repeated  and  violent  paroxysms,  and  the 
gross  deforming  changes  sometimes  met  with  after  a  few  and  less 
intense   attacks  of  local   gouty  disease.      These  varying  degrees 


ARTHRITIS    DEFORMANS    URATICA.  26  I 

and  results  of  arthritis  are  not  more  remarkable  than  the  occur- 
rence of  the  tophaceous  form  of  gout  already  treated  of,  in  which 
there  must  also  exist  some  personal  factor  or  idiosyncrasy. 

The  fingers,  hands,  and  wrists  show  various  deformities,  depend- 
ing on  overgrowth  of  articulating  ends  of  bone,  cartilage,  liga- 
ments, and  bursas.  These  may  be  complicated  with  visible  or 
invisible  tophaceous  deposits.  Partial  dislocations  of  phalanges 
may  occur,  and  deflections  of  these  in  various  directions.  A 
common  site,  even  in  slightly  pronounced  cases,  is  the  metacarpo- 
phalangeal joint  of  the  first  finger.  As  I  have  mentioned  pre- 
viously, ankylosis  may  occur,  both  true  and  false,  the  former  being 
quite  peculiar  to  gouty  arthritis.  Superjacent  bursas  tend  to 
become  large  and  loose,  or  may  contain  uratic  deposits,  and  the 
latter  may  occur  in  nodular  form  in  the  pulps  of  the  fingers  and 
thumbs.  The  affected  joints  are  apt  to  crack  audibly  on  move- 
ment, and  a  crunching  sensation  is  imparted  to  the  hand  if  placed 
over  a  large  one,  such  as  the  knee.  This  sign  is,  however,  not 
peculiar  to  chronic  gouty  arthritis.  It  is  very  rare  for  the  defor- 
mities of  true  gout  to  attain  the  gross  characters  peculiar  to  chronic 
rheumatic  arthritis ;  they  are  altogether  of  lesser  degree  in  the 
majority  of  the  worst  instances.  Hydrarthrosis  is  less  commonly 
due  to  gout  than  to  rheumatism.  Some  degree  of  synovial  effusion 
is  very  often  met  with.  Gouty  arthritis  will,  however,  provoke 
exostoses,  which  are  due  rather  to  irritative  ostitis  than  to  pro- 
liferation of  encrusting  cartilage. 

The  patellas  may  enlarge  considerably  and  lose  their  sharp  edges; 
their  cartilages  are  rarely  found  intact,  but  are  eroded,  cracked, 
and  often  encrusted  with  urates.  The  sufferers  sometimes  com- 
plain more  of  helplessness  than  of  painfulness  in  chronic  gout  of 
the  knee,  the  leg  having  a  tendency  to  yield  and  give  way  suddenly 
on  exertion. 

In  chronic  gout  affecting  the  feet,  there  are  both  pain  and 
weakness.  The  ankle  is  a  site  for  long-abiding  gout,  and  so, 
too,  are  the  component  joints  of  the  tarsus.  Repeated  subacute 
attacks  are  very  prone  to  seize  upon  various  parts  of  the  feet,  as 
on  the  outer  or  inner  aspects  of  the  tarsus,  the  heel,  tendo 
Achillis,  and  the  plantar  fascia.  Painful  states  of  single  tarsal 
bones  occur  with  nodular  swelling.  Such  patients  are  sorely 
crippled  and  hampered  in  their  efforts  at  locomotion.  Varied 
deflections  of  the  toes  occur,  as  in  the  fingers,  but  the  tendency 
is  for  distortion  outwards  of  each  great-toe,  sometimes  to  an 
extreme  degree,  whereby  the  two  component  phalanges  quite 
overlap  the  other  digits.      This  is  a  permanent  and  irremediable 


262  CLINICAL   VARIETIES    OF    GOUT. 

deformity.  I  have  already  described  the  formation  of  gouty 
Heberden's  nodes,  which  may  be  seen  in  both  sexes,  but  with 
greater  frequency  in  women ;  also  the  tuberous  or  knotty  state 
of  the  small  joints  in  the  latter  sex,  which  afford,  as  I  believe, 
strong  indications  of  a  gouty  habit  of  body.  With  these  are 
found  various  deflections  of  the  last  phalanges,  especially  of  the 
little,  ring,  and  fore-fingers.  Both  the  nodes  and  distortions  in 
such  cases  belong  rather  to  the  category  of  incomplete  than 
of  chronic  gout,  since  they  are  rarely  attended  by  any  regular 
manifestations  or  sharp  paroxysms,  but  are  associated  rather  with 
hemicrania,  and  various  vascular  and  nervous  symptoms,  and 
sometimes  with  glycosuria. 

Deformities  such  as  I  have  described  may  be  borne  for  many 
years  in  persons  of  originally  vigorous  constitution,  and  advanced 
age  may  be  reached  in  spite  of  severe  crippling. 

With  the  establishment  of  chronic  gout  in  either  its  tophaceous 
or  deforming  varieties,  it  is  rare  to  find  the  kidneys  in  a  healthy 
or  adequate  condition.  In  the  earlier  paroxysms  these  organs 
may  be  little,  if  at  all,  involved.  The  patients  may  notice  occa- 
sional uratic  deposits,  but  it  is  a  common  experience  that,  as  the 
gouty  fits  lessen  in  intensity  and  frequency,  the  urine  becomes 
less  apt  to  be  loaded,  and  is  observed  to  be  more  plentiful  and 
clear.  This  symptom  may  be  noted  by  the  patient,  and  is  not 
seldom  regarded  by  him  as  a  satisfactory  indication  of  better 
general  health  and  of  less  goutiness.  The  observant  physician 
will  form  a  different  opinion  on  this  fact,  and  take  note  of  the 
condition  of  the  urine  as  to  its  quantity,  specific  gravity,  and  the 
percentage  of  urea  and  uric  acid  contained  in  it.  In  particular, 
he  will  ascertain  if  albumen  be  present  in  even  small  amount. 
Albuminuria  has  been  observed  to  set  in  within  a  year  or  two  of 
the  first  overt  gouty  attacks.  In  such  cases  it  is  only  too  common 
to  find  that  with  some  polyuria  there  is  low  specific  gravity,  1006 
to  1015,  a  deficient  amount  of  urea  and  uric  acid,  and  a  small 
quantity  of  albumen.  The  latter  may  be  absent  for  long  periods, 
but  is  usually  fleeting  if  in  small  amount.  These  qualities  betoken 
the  onset  of  interstitial  nephritis,  with  some  degree  of  tubal  catarrh, 
and  indicate  one  of  the  gravest  complications  or  phases  of  chronic 
gout.  It  is  then  certain  that  one  variety  of  visceral  gout  has 
supervened,  and  the  general  disease  is  thus  rendered  more  grave 
and  less  amenable  to  treatment.  This  phase  is  more  apt  to 
appear  in  cases  of  tophaceous  gout,  and  some  ratio  is  established 
between  the  degree  of  renal  inadequacy  and  the  amount  of  uratic 
deposit  laid  down  in  or  around  the  joints.      Microscopic  examina- 


ARTHRITIS    DEFORMANS    URATICA.  26 


J 


tion  of  the  urinary  sediment  reveals  in  these  cases  a  few  casts  of 
the  tubules,  epithelial  or  granular.  These  are  not  constantly 
detectible,  but  may  be  found  at  intervals,  and  especially  during 
subacute  articular  attacks.  Unless  tubal  catarrh  is  present  to  a 
considerable  extent,  no  large  amount  of  albumen  is  met  with  in 
the  urine  in  cases  of  chronic  gout.  The  morbid  appearances  in 
the  kidney  have  already  been  described  in  Chapter  iv.,  p.  99.  I 
do  not  believe  that  uratic  deposits  in  the  tubules,  or  outside  them, 
as  found  sometimes  in  the  pyramids,  are,  as  is  often  affirmed,  an 
important  cause  of  albuminuria.  Intimately  connected  with,  and 
indeed  dependent  on,  the  progressive  renal  changes  are  certain 
cardio-vascular  alterations  which  have  in  recent  times  received 
much  attention  and  close  study  from  many  good  observers.  I 
have  given  an  account  of  these  so  far  as  their  morbid  anatomy  is 
concerned.  The  associated  symptomatology  of  these  changes  may 
be  noted  here.  Indications  are  afforded  of  the  hypertrophy  of  the 
left  ventricle  of  the  heart  by  the  ordinary  physical  signs  of  forcible 
impulse,  displaced  and  diffused  apex-beat,  and  by  the  noisy  quality 
of  the  first  cardiac  sound.  This  is  often  replaced  by  a  reduplicated 
first  sound,  heard  at  the  apex,  over  the  septum  of  the  ventricles 
and  at  the  base.  The  aortic  second  sound  is  apt  to  be  loud  or 
accentuated.  The  systemic  arteries  become  hardened,  and,  where 
superficial,  visible,  tortuous,  and  possibly  atheromatous.  The 
pulse  is  of  high  tension,  full  between  the  beats,  and  firm — pul- 
sus durus.  This  is  commonly  an  abiding  condition,  but  the  ten- 
sion may  vary,  and  the  pulse  become  relaxed  or  compressible  in 
response  to  several  conditions. 

Such  symptoms  differ  in  no  way  from  those  commonly  asso- 
ciated with  interstitial  nephritis,  however  induced.  Hence,  they 
are  not  peculiar  to  the  gouty,  though  so  often  met  with  in  such 
persons.  The  longer  this  condition  persists,  the  greater  the  risk 
for  the  patient,  since  he  becomes  liable  to  the  several  untoward 
accidents  of  arterial  sclerosis  with  high  arterial  blood-pressure, — 
to  wit,  haemorrhages  in  vital  or  essential  organs,  and  especially  in 
the  brain  or  retina ;  and,  in  truth,  the  condition  tends  to  progress 
pari  passu  with  the  advance  of  renal  contraction. 

Todd  related  a  case  where  albuminuria  occurred  two  years  after 
a  primary  attack  of  gout,  and  death  ensued  two  years  later  after 
ureemic  eclampsia  and  coma. 

In  chronic  gout  there  is  always  defective  excretion  of  uric  acid 
by  the  kidneys,  and  an  excess  of  this  acid  in  the  blood.1 

1  In  respect  of  the  intimate  pathology  of  cases  of  cardio-vascular  disease  in  rela- 
tion to  interstitial  nephritis,  a  new  view  has  been  taken  by  Dr.  Da  Costa  of  Phila- 


264  CLINICAL   VARIETIES    OP   GOUT. 

Pulmonary  emphysema  is  another  textural  degeneration,  which 
tends  to  proceed  with  much  risk  and  suffering  to  the  gouty, 
adding  to  the  difficulties  of  the  circulation,  and  aggravating  the 
cardiac  trouble,  already  existing,  by  causing  dilatation  and 
leather-like  induration  of  the  right  ventricle. 


Gouty  Cachexia. 

This  condition  supervenes  gradually  in  cases  of  chronic  gout, 
and  represents  the  final  stage  of  the  various  evils  wrought  by 
this  malady  on  the  constitution.  Gout  occurring  at  an  early  age, 
and,  therefore,  especially  significant  of  strong  hereditary  tendency, 
may  within  a  few  years  induce  this  state,  and,  so,  men  in  the 
prime  of  life  may  be  the  subject  of  it.  Women  under  fifty  years 
of  age  very  rarely  afford  examples  of  it.  I  have  met  with  at 
least  one  instance  in  a  woman  aged  forty. 

Regular  gout  in  robust  men  who  have  not  abused  their  health 
by  excesses  of  any  kind  seldom  passes  on  to  the  stage  of  cachexia. 
The  case  is  very  different  when  the  disease  is  implanted  or  in- 
duced in  persons  of  originally  feeble  constitution.  In  such 
instances  the  gouty  processes  are  atonic,  and  indicate  a  gene- 
rally asthenic  condition.  The  health  fails,  the  blood  becomes 
impoverished,  the  circulation  flags,  signs  of  early  senility  super- 
vene with  widespread  textural  degenerations,  and  the  kidneys 
become  rapidly  inadequate  for  their  functions. 

Gouty  cachexia  may  form  the  last  phase  of  either  tophaceous 
or  deforming  gout.  The  cases  of  extreme  "  chalky "  gout  are 
also  examples  of  gouty  cachexia.  Subacute  attacks  in  the  joints 
may  occur  from  time  to  time,  tending  to  linger  long  in  the  parts, 

delphia.*  He  and  Dr.  Longstreth  have  carefully  examined  the  nervous  ganglia  of  the 
renal  plexu3  and  the  cervical  ganglia  giving  origin  to  the  cardiac  nerves  in  cases  of 
this  nature.  They  found  well-marked  changes,  showing  increased  fibrous  tissue  and 
atrophy  of  the  ganglionic  cells.  Dr.  Saundby  has  also  noted  this  alteration  in  the 
renal  ganglia.  Dr.  Da  Costa  asks,  "  Is  it  going  too  far  to  assume  that  these  changes 
are  an  integral  part  of  the  disease,  and  in  the  case  of  the  cardiac  ganglia  determine 
the  hypertrophy  ?  .  .  .  What  starts  the  change  ?  What  is  the  cause  of  the  dege- 
neration ?  Is  it  not  fair  to  look  beside  the  blood,  to  a  cause  so  predominant  as 
the  nervous  influence,  which  is  everywhere  ?  What  the  ultimate  cause  of  the  lesion 
is  cannot  be  stated,  nor  need  we  assume  that  one  cause  alone  will  determine  it.  It 
may  be  gout,  it  may  be  lithasmia,  it  may  be  rheumatism,  it  may  be  lead,  it  may  be 
purely  perverted  nervous  function  from  worry,  from  strain,  from  anxiety."  He  con- 
cludes, that,  "  the  cardiac  hypertrophy  in  Bright's  disease  is  not  in  any  sense  the  con- 
sequence of  that  disease,  but  an  integral  part  of  the  same  general  morbid  process." 
This  is  the  view  of  Gull  and  Sutton  from  another  stand-point. 

*  The  Middleton-Goldsmith  Lecture,  April  1888.     Med.  News,  May  1888. 


GOUTY    CACHEXIA.  265 

and  to  subside  imperfectly,  leaving  cedema  and  tenderness  behind 
them.  Slight  provocations  suffice  to  induce  renewed  attacks, 
trivial  injuries  and  exposure  to  cold  being  often  determinant  of 
such.  The  patient  is  crippled,  and  unable  to  take  any  kind 
of  exercise  beyond  that  of  conveyance  in  some  vehicle.  He  is  a 
confirmed  invalid.  Irregular  forms  of  gout  may  be  also  induced 
by  slight  causes  in  various  parts  of  the  body. 

The  renal  inadequacy  is  often  very  manifest,  and  sets  up 
dropsy  with  minor,  or  even  grave,  ursemic  symptoms.  Pulmonary 
cedema,  bronchitis,  the  many  troubles  inseparable  from  cardiac 
failure,  dilative  hypertrophy  of  both  ventricles,  hepatic  engorge- 
ment, gastric  catarrh,  and  diarrhoea  may  all  gradually  supervene, 
and  portend  a  fatal  issue.  These  conditions  may  be  successfully 
met  again  and  again  by  treatment,  but  surely  wear  out  the  patient ; 
or  death  may  rapidly  be  brought  about  by  an  attack  of  pneumonia, 
especially  when  it  seizes  on  a  lung  already  emphysematous. 

The  onset  of  gouty  cachexia  in  any  case  is  always  to  be 
dreaded,  and,  therefore,  to  be  anticipated  early  by  preventive  and 
other  modes  of  treatment.  So  long  as  regular  attacks  occur  at 
long  intervals,  there  is  little  fear  of  drifting  into  the  cachectic 
stage.  The  tendency  varies  exactly  with  the  intensity  of  the 
gouty  habit,  the  general  management  of  the  case,  and  the  forti- 
tude of  the  patient  in  respect  of  self-control.  The  wilful  libertine, 
if  gouty,  is  likely  soon  to  become  cachectic,  while  the  prudent 
man  may  altogether  avoid  this  state,  or  avert  its  evils  for  many 
years  or  decades  of  years. 

The  anatomical  basis  of  gouty  cachexia  is  represented  by 
widely  spread  tissue-degenerations,  of  which  I  have  already 
treated.  Arterial  sclerosis,  fatty  changes  with  fibrosis  in  various 
viscera,  interstitial  nephritis,  degeneration  of  cardiac  walls,  pul- 
monary emphysema,  and  catarrhal  states  of  mucous  surfaces 
generally,  are  the  essential  pathological  lesions.  It  is  readily 
intelligible  that  the  symptoms  arising  from  these  conditions  must 
be  manifold  and  infinitely  varied,  some  appearing  soon,  and 
others  later.  I  will  enumerate  the  most  characteristic  of  these. 
They  may  not  all  be  met  with  in  any  one  case. 

Anaemia  is  apt  to  supervene  in  chronic  gout,  though  forming  no 
part  of  the  disease  in  its  acute  forms.  Some  degree  of  dyspnoea 
is  common,  being  variously  induced  by  renal,  cardiac,  or  pul- 
monary degenerations,  or  by  a  combination  of  all  three.  The 
pulse  is  irritable  and  easily  rendered  unduly  frequent.  There 
may  be  palpitation,  and  various  cardiac  symptoms  dependent  on 
the  existing  lesions  and  degree  of  failure  of  the  heart's  walls. 


266  CLINICAL   VARIETIES    OF    GOUT. 

More  or  less  bronchial  catarrh  is  frequent,  and  oedema  of  the 
bases  of  the  lungs.     Slight  provocations  readily  induce  bronchitis. 

The  digestion  is  feeble  and  painful,  flatulency  and  indications 
of  gastro-enteric  catarrh  being  present.  Pharyngeal  catarrh  may 
be  troublesome,  exciting  hacking  cough,  especially  in  the  morn- 
ing. Diarrhoea  may  occur  from  time  to  time.  The  condition  of 
the  urine  is  closely  dependent  on  the  condition  of  the  kidneys, 
and  presents  generally  the  characters  common  to  chronic  scleros- 
ing nephritis.  Polyuria  may  be  present  for  short  periods,  and 
remit.  Glycosuria  in  varying  degree,  or  fugitive,  may  be  some- 
times noted.  Albuminuria  also  varies  in  degree,  and  may  remit 
for  long  periods. 

The  cerebral  or  psychical  state  is  not  constant.  There  may  be 
much  nervous  irritability  and  varying  degrees  of  amnesia.  The 
latter  is  sometimes  very  marked.  Gloomy  and  melancholic  states 
of  mind  may  prevail,  with  miserable  dejection  of  spirits.  Stupor, 
loss  of  consciousness,  and  a  state  of  catalepsy  with  vacant  stare, 
have  all  been  noted  as  temporary  accompaniments  of  gouty 
cachexia. 

Somnolence,  especially  after  meals,  may  occur,  also  vertigo, 
syncopal  tendency,  tinnitus  aurium,  and  diplopia.  Fatuity,  hebe- 
tude, or  muttering  delirium,  are  sometimes  met  with  in  the  last 
stages.  The  complexion  may  become  sallow  and  dirty  yellow,  as 
in  chronic  nephritis.  The  hair  is  apt  to  whiten  prematurely. 
Ultimately,  signs  of  dropsy,  due  to  cardiac  failure  for  the  most 
part,  tend  to  appear  in  the  lower  limbs.  A  cerebral  haemorrhage 
may  induce  hemiplegia,  or  prove  rapidly  fatal,  or  the  end  may  be 
reached  after  the  onset  of  bronchitis  or  pneumonia.  Death  may 
also  occur  from  syncope,  or  from  rupture  of  the  left  cardiac  ven- 
tricle, which  has  become  fatty. 

Gouty  Vascular  Cachexia.  —  Sometimes,  the  onset  of  gouty 
cachexia  is  manifested  by  a  general  feebleness  of  bodily  power, 
inability  for  wonted  exercise  being  manifested.  In  this  way,  vigo- 
rous old  men,  who  have  been  long  more  or  less  gouty,  begin  to 
break  down.  There  may  be  no  uratic  deposits,  but  there  is  often 
polyuria,  at  times  paroxysmal  and  nocturnal,  and  the  urine  is 
indicative  of  granular  kidneys.  There  is  reason  to  believe  that 
some  of  these  failures  are  largely  due  to  vascular  degeneration, 
which  is  wide-spread,  and  thus  involves  the  intimate  nutrition  of 
the  cerebro-spinal  centres.  Some  bodily  wasting  is  observable, 
together  with  muscular  and  nervous  enfeeblement. 


IRREGULAR   GOUT.  267 


Irregular  (Incomplete;  Gout. 

Many  terms  have  been  applied  to  phases  of  gout  which  do  not 
manifest  themselves  in  classical  fashion  in  a  joint.1  One  more 
may  be  added,  which  will  concisely  express  the  relation  which 
these  forms — for  they  are  many — bear  to  the  acute  and  regular 
fits  of  the  disorder,  viz.,  abarticular.  Gout  manifesting  itself  any- 
where but  in  a  joint  is  to  be  considered  irregular  or  incomplete. 
Such  phases  of  the  disease  may  be  anomalous,  but  they  are  very 
common,  and  as  such  are  so  far  regular  as  to  comprehend  a 
number  of  ailments  which  pertain  chiefly,  and  in  some  cases  exclu- 
sively, to  persons  of  gouty  heritage  and  diathesis.2 

In  discussing  these  varieties  of  gouty  disease,  it  is  of  the 
utmost  importance  to  seek  exactness,  and  only  to  include  in  the 
category  such  ailments  as  may  legitimately  find  a  place  there. 
Without  doubt  many  morbid  states  have  often  been  flippantly 
or  erroneously  set  down  to  irregular  gout  which  owned  no  such 
designation,  and  thus  a  cloak  for  ignorance  has  always  been 
at  hand  to  throw  over  careless  observation,  ignorance,  or  wilful 
misinterpretation  of  symptoms.  As  a  consequence  of  such  errors, 
some  have  come  to  regard  even  truly  gouty  manifestations,  when 
not  articular,  as  actually  non-existent,  and  to  deny  the  depen- 
dence of  such  upon  a  gouty  habit.  The  latter  error  is  no  more  to 
be  condoned  than  the  former,  and  it  may  be  fraught  with  mischief 
to  the  sufferer. 

Senator  expresses  his  belief  that  irregular  gout  is  evolved  from 
the  typical  form  when  the  latter  has  existed  for  many  years,  and 
that  it  is  met  with  chiefly  in  elderly  people.3  This  is  without 
doubt  the  case  in  a  certain  proportion  of  instances,  but  this  view 
will  not  explain  the  existence  of  symptoms  and  numerous  ailments 
which  occur  in  the  persons  of  those  who  are  goutily  disposed, 
who  are  entitled  to  gout,  and  whose  bodily  disorders  are  plainly 
impressed  with  the  gouty  type.  The  minor,  incomplete,  and  less 
well-marked  forms  of  gouty  trouble  are  precisely  those  that  have 
so  long  escaped  exact  recognition,  and  which  even  now  do  not 
readily  receive  this  explanation. 

Many  of  the  irregular  phases  of  gout  are  recognized  by  some 


1  On  this  subject,  "  Arthritis  Anomala,"  the  masterly  treatise  of  Musgrave,  written 
in  1707,  is  well  worthy  of  study. 

2  Such  epithets  are  "lurking,"  "latent,"  "misplaced,"  "undeveloped,"  "atonic," 
"suppressed,"  "masked,"  "imperfect,"  "incomplete,"  "asthenic,"  "vague,"  "erra- 
tic." "anomalous." 


tic,"  "  anomalous." 

3  Art.  in  Ziemssen's  Cyclopaedia. 


2  05  CLINICAL    VARIETIES    OF    GOUT. 

as  results  of  lithaemia,  and  in  no  special  relation  to  gout.1  But 
lithEemia  or  urichaernia  is  an  uric  acid  disease,  and — no  litbasmia, 
no  gout. 

I  have  already  expressed  my  belief  that  in  many  instances  the 
disorders  attributed  to  lithaamia  are  truly  expressions  of  incom- 
plete gout.  They  portend,  if  they  do  not  ultimately  lead  up  to, 
true  gout.  Some  persons  are  only  so  far  gouty  as  to  be  litheemic 
without  manifesting  any  joint-disturbances.  They  may  never  be 
the  subjects  of  regular  gout,  or  many  years  may  elapse  before 
this  event  supervenes.  Allusion  has  also  been  made  to  many 
varieties  of  irregular  gout  in  Chapter  viii. 

Manifestations  of  it  may  be  met  with  in  both  sexes,  women, 
however,  being  especially  prone  to  them,  more  so  at,  or  soon  after, 
the  climacteric  period.  So  multiform  are  these,  that  the  epithet 
"  Protean  "  has  been  applied  to  them. 

Much  difficulty  attends  the  diagnosis  of  minor  gouty  ailments 
in  many  cases,  because  regard  is  mostly  had  to  some  very  plain 
tokens  of  the  disease.  Thus,  it  is  common  to  hear  objection  made 
to  an  opinion  as  to  the  truly  gouty  nature  of  a  case,  because  no 
tophaceous  deposits  can.be  found,  or  no  history  of  an  attack  in  a. 
big-toe  at  some  previous  period  is  obtainable.  And  again  it  is 
objected  that  there  can  be  no  gouty  element  because  the  patient 
has  earned  the  right  to  the  ailment  neither  by  heredity  nor  by 
his  personal  habits. 

In  opposition  to  doubts  of  this  nature,  I  am  most  deeply 
impressed  with  the  fact  that  it  is  just  in  cases  where  no  marked 
coarse  objective  signs  of  gout  exist  that  we  should  look  for  the 
presence  of  the  minor  tokens  of  the  affection,  and  just  in  such 
cases  that  we  commonly  find  them.  Irregular  and  incomplete 
gouty  symptoms  occur  both  in  those  who  are  the  victims  of 
regular,  exquisite,  attacks,  and  in  persons  who  have  never  had, 
and,  perchance,  may  never  have,  a  typical  precipitation  of  regular 
gouty  inflammation.  The  most  marked  instances  are  certainly 
to  be  found  amongst  the  latter  class,  although  even  in  these  it 
is  never  safe  to  predict  immunity  from  a  regular  attack,  since 
such  may  not  supervene  till  the  ninth  or  tenth  climacteric  period 
of  life. 

A   study   of  the   irregular   phenomena    of   gout    is    of   much 

1  Some  physicians  will  not  regard  any  disturbance  as  truly  gouty  unless  positive 
demonstration  of  aberrant  relations  of  uric  acid  be  made,  and  for  them  nothing  is 
gout  that  is  not  essentially  connected  with  paroxysmal  attacks  in  joints.  This  is,  in 
truth,  but  an  elementary  fact  in  the  whole  pathology  of  gout,  the  first  conception  of 
the  malady  as  defined  in  simple  form  for  a  junior  student.  Careful  clinical  study 
teaches  many  other  facts  about  the  disease  and  its  relationships. 


IRREGULAR   GOUT.  269 

importance,  and  tends  to  shed  light  upon  the  nature  of  the 
disorder,  or  at  least  to  clear  the  way  for  a  better  knowledge  of 
its  laws. 

It  is  to  be  noted  that  phases  of  irregular  gout  may  occur  in  those 
who  suffer  occasionally  from  regular  attacks  ;  but  probably  the 
majority  of  cases  are  seen  in  persons  who  have  never  had  frank 
gouty  arthritis.  Hence,  it  may  be  affirmed  that,  for  the  most  part, 
regular  or  sthenic  attacks  are  preventive  of  the  irregular  or 
masked  phases  of  the  disorder.  Some  patients  become  aware  of 
this  fact,  and  endeavour,  imprudently,  to  bring  their  gout  out,  or 
to  focus  it,  as  it  were,  in  a  regular  fashion  in  some  joint.  They 
have  learned  to  dread  its  insidious  actions,  and  prefer  the  honest 
malady  in  a  classical  form. 

Many  of  the  ailments  due  to  irregular  gout  are  often  regarded, 
both  by  the  practitioner  and  the  patient,  as  "  rheumatic "  or 
"  neuralgic,"  and  much  confusion  has  arisen  in  consequence.  The 
diagnosis  is,  in  truth,  often  very  difficult,  demanding  nice  and 
painstaking  discrimination  if  we  would  be  accurate  and  honest. 
I  have  already  remarked  that  not  every  ailment  or  illness  in  a 
truly  gouty  person  is  of  gouty  nature ;  much  less  so  is  this  the 
case  in  the  subjects  of  gouty  tendency  which  is  only  slightly 
impressed  upon  them. 

The  true  nature  of  the  symptoms  is  to  be  ascertained  by  a 
consideration  of  the  physiognomy,  family  and  personal  life- 
history  of  the  individual,  and  by  attention  to  the  type  of  the 
particular  ailment.  The  crucial  test  as  to  the  presence  of  uric- 
hsemia  is  seldom  practicable  in  any  but  hospital  patients,  so 
that  we  must  often  be  content  to  act  in  ignorance  of  this  impor- 
tant fact. 

Considerations  as  to  family  proclivity,  personal  habits,  age  and 
sex,  will  usually  avail  materially,  if  not  absolutely,  to  throw  light 
on  the  true  characters  of  the  symptoms  presented  ;  but  cases  will 
occur  in  which  the  best  observers  may  be  misled,  and  a  correct 
diagnosis  only  be  possible  on  the  onset  of  some  unmistakable 
gouty  manifestation  elsewhere.  When  the  latter  is  not  forth- 
coming, the  clue  is  sometimes  at  hand  by  therapeutic  tests.  A 
large  bedside  experience  is  commonly  requisite  to  unravel  some 
of  the  strange  problems  presented  by  masked  gouty  processes. 
This  necessarily  entails  a  wider  grasp  of  all  forms  of  morbid 
phenomena  than  is  possible  for  him  whose  mind  is  mainly  directed 
to  the  study  of  one  disease,  and  thereby  warped. 

A  study  of  the  multiform  features  of  irregular  gout  is  of  great 
importance,  since  they  often  betoken  grave  states  of  ill-health, 


270  CLINICAL   VARIETIES    OF    GOUT. 

leading  more  surely  to  death  than  any  number  of  frank  attacks  of 
gout.  Hence  the  dictum  of  Musgrave  1  should  be  borne  in  mind, 
"  Arthritis  raro  occidit  Regularis,  raro  nisi  prius  degenerans  in 
Anomalam."  Sir  Thomas  Watson  quoted  some  French  author  for 
the  following  aphorism,  which  would  serve  as  a  fair  translation  of 
Musgrave's  sentence :  "  La  goutte  articulaire  est  celle  dont  on  est 
malade,  et  la  goutte  interne  est  celle  dont  on  meurt." 

It  is  an  error  to  suppose  that  the  irregular  manifestations  of 
gout  are  mostly  witnessed  in  the  affluent  classes  of  society.  Hos- 
pital practice  furnishes  numerous  examples,  if  they  be  sought  for 
and  detected.  Hard-worked  men  living  in  towns,  whose  occupa- 
tions are  mainly  sedentary,  suffer  in  considerable  proportion,  and 
especially  are  those  affected  who  use  their  brains  and  undergo 
great  mental  labour.  In  such  instances  there  is  often  found  to 
be  a  large  appetite  for  food  ;  for  brain-work  and  wear  of  the  nervous 
textures  will,  equally  with  muscular  energy,  create  this  ;  but  a 
limit  is  placed  to  sufficient  oxydation  by  reason  of  the  necessary 
urban  and  confined  life,  and  the  consequent  defective  aeration. 
If  no  relief  be  afforded,  a  measure  of  dyspepsia  ensues,  usually  of 
catarrhal  form,  and  pains  and  fulness  are  complained  of  in  the 
liver.  A  sort  of  cumulative  plethora  is  thus  from  time  to  time 
set  up,  and  it  is  at  such  crises  that  a  sudden  precipitation  of 
gouty  inflammation  may  be  looked  for.  A  regular  attack  of  acute 
gout  may  occur,  or,  if  no  special  depressing  cause  comes  into  play, 
then  some  minor  or  irregular  token  of  gout  appears. 

In  the  cases  of  those  who  lead  very  uniform  and  regular  lives, 
these  troubles  occur  if  the  gouty  taint  is  present ;  but  the  pro- 
clivity is  much  aggravated  by  indiscreet  indulgence  in  food  or 
drink,  or  by  undue  exposure  to  chill  and  changeable  weather. 

Sir  Prescott  Hewett's  remarks  on  some  of  the  irregular  mani- 
festations of  gout  are  particularly  apt  and  instructive.2  He  refers 
to  "  dyspepsia,  more  or  less  troublesome ;  frequent  deposits  of 
lithates  ;  slight  eczematous  eruptions  from  time  to  time  ;  anoma- 
lous pains  in  various  muscles ;  sharp,  deep-seated  paiD  in  the 
tongue,  existing  for  two  or  three  days,  and  then  disappearing 
altogether  for  a  while ;  crackling  about  the  cervical  spine  in 
slight  movements,3  more  or  less  ;  sometimes  a  mere  suspicion 
of  knottiness  about  the  smaller  joints  of  the  fingers."  And  he 
adds,  "  The  great  difficulty  in  such  an  investigation  is  to  get  at 

1  Be  Artliritide  Anomald,  Corollaria  ii.,  p.  474.    Exon.,  1707. 

2  Clin.  Soc.  Trans.,  vol.  vi.,  1873. 

3  Crackling  sensation  in  the  upper  part  of  the  spine  was  recognized  by  Brodie  in 
1842  as  a  gouty  symptom,  and  he  related  having  met  with  several  cases.  I  have  also 
observed  it. 


IRREGULAR    GOUT.  2/1 

a  clear  recognition  of  such  trifles,  for,  disappearing  as  they  do  for 
a  while,  they  are  forgotten  until  recalled  to  the  mind." 

I  believe  that  many  of  the  anomalous  pains  above  described, 
in  muscular,  fibrous,  synovial,  and  articular  structures,  are  truly 
gouty  in  their  nature,  but  they  are  more  frequently  ascribed  to 
"  rheumatic  "  influences. 

Amongst  minor  signs  of  incomplete  gout  are  the  nodosities  of 
the  fingers  already  described,  with  or  without  more  marked  dis- 
tortions of  the  phalanges  or  entire  digits. 

I  have,  on  several  occasions,  had  the  opportunhty  of  watching 
the  course  followed  by  small  gouty  formations,  resembling  a  crab's 
eye,  over  Heberden's  nodes.      Garrod  refers  to  these. 

In  the  earliest  stage  a  small  eminence  was  observed,  which 
was  slightly  tender.  It  became  full  of  a  clear  fluid,  and  was 
prone  to  ache  and  cause  a  sensation  of  burning.  It  enlarged  and 
burst  at  intervals,  emitting  a  pellucid  and  sticky  fluid.  It  was 
solitary,  and  in  no  way  connected  with  the  last  phalangeal  joint. 
On  examining  the  fluid  microscopically,  I  could  find  no  uratic 
formations,  and  no  chalky  matter  appeared.  The  whole  subsided 
for  months  together,  and  re-formed  exactly  as  before.  These  for- 
mations can  hardly  be  called  tophaceous,  inasmuch  as  no  salts 
of  uric  acid  are  deposited.  They  occur,  probably,  in  small 
bursal  sacs.  Sir  James  Paget  has  described  these  growths,  and 
deprecates  any  surgical  interference  with  them.  If  let  alone, 
their  tendency  is  to  rupture  and  to  subside  along  with  the 
quiescence  of  the  gouty  activity  that  gave  rise  to  them.  Some 
little  thickening  of  the  integument  is  all  that  can  be  found  in  the 
intervals. 

The  gouty  nodosities  are  often  red,  and  are  prone  to  become 
hot  and  painful  from  various  causes.  Fugitive  achings  are  fre- 
quent in  them  whenever  a  threatening  of  fresh  attacks  super- 
venes, and  they  are  specially  apt  to  be  troublesome  after  partak- 
ing of  bad  champagne  or  other  gout-inducing  wines. 

The  metacarpo-phalangeal  joint  of  the  right  thumb  is  fre- 
quently enlarged,  and  excessive  use  of  this  part  in  writing,  or 
in  other  manual  labour,  has  possibly  much  to  do  with  its  special 
liability  to  suffer. 

These  deformities  of  the  finger-joints  are  to  be  met  with  in 
women,  who  seldom  present,  in  as  marked  form  as  males,  either 
the  physiognomical  features  or  the  tissue-changes  of  the  gouty 
diathesis.  I  have  met  with  them  before  the  menopause.  Thev 
are  to  be  distinguished  from  true  gouty  deformities  of  the  fingers 
in  both  sexes,  both  by  their  tuberous  form  and  by  the  fact  that 


272  CLINICAL    VARIETIES    OF   GOUT. 

they  are  not  always  the  result  of  an  acute  (gouty)  arthritis. 
And  they  must  not  be  confounded  in  any  case  with  the  grosser 
changes  brought  about  by  rheumatic  osteo- arthritis,  in  which  also 
the  axes  of  the  fingers  commonly  diverge  to  the  ulnar  side  of  the 
forearm. 

It  has  long  been  recognized  that  gouty  manifestations  in 
women  are  different  from  those  observed  in  men.  Distinct  gouty 
inflammation  is  not  usual  in  women  till  the  "  change  of  life  " 
has  occurred.  But  it  is  found  that  gouty  headache,  migraine, 
and  dysmenorrhcea  occur  before  that  period  in  the  subjects  of 
inherited  gout,  and  are  indeed  sometimes  the  only  expressions  of 
such  hereditary  tendency.1  I  have  observed  that  menorrhagia, 
severe  headaches,  and  migraine  occur  with  some  frequency  in 
women  of  gouty  parentage.  The  worst  case  of  epistaxis  in  a 
young  woman  that  I  ever  witnessed  was  in  the  daughter  of  an 
exceedingly  gouty  man.  Without  doubt,  all  these  ailments  in 
such  persons  yield  more  distinctly  to  anti-gouty  treatment  than 
to  any  other  mode  of  medication. 

Plantar  gout  is  an  irregular  form  of  the  disorder,  and  has  not 
been  hitherto  particularly  described.  It  is  very  agonizing,  and 
may  attack  both  soles  simultaneously,  hard  swellings  being 
formed  gradually  in  the  fasciae.  It  begins  subacutely,and  is  apt 
to  linger  for  many  weeks.  Achings  in  the  insteps  are  common 
symptoms,  with  a  sensation  as  if  a  tight  boot  were  worn.  No 
redness  is  seen,  but  some  painful  induration  may  be  found  over  a 
tarsal  bone,  which  subsides  very  gradually,  together  with  the  asso- 
ciated painfulness. 

Deep-seated  pain  in  the  heel  has  been  recognized  as  of  gouty 
origin.  The  sensation  is  compared  to  the  feeling  of  a  foreign 
body  being  implanted  there,  such  as  a  bullet.  And  it  is  note- 
worthy that  this  is  sometimes  a  symptom  of  a  renal  calculus, 
which  may  itself  be  the  outcome  of  gouty  taint.  The  pain  is 
sometimes  distinctly  in  the  tendo  Achillis.  The  coccyx  is  also 
the  seat  of  gouty  pain.  I  feel  sure  that  a  dull  aching  pain  in 
the  ensiform  cartilage  is  sometimes  of  this  nature.  The  tender- 
ness may  be  extreme ;  it  comes  and .  goes  somewhat  suddenly, 
and  some  degree  of  hepatic  discomfort  is  mostly  associated  with 
it.      Pain  is  especially  felt  on  stooping. 

Amongst  the  irregular  forms  of  gout  which  occur  in  other 
than  articular  structures  are  the  aching  and  boring  pains  in 
certain  muscles  and  muscular  groups.  The  adductors  of  the 
thigh    and   the  gastrocnemii  are  apparently  especially  liable  to 

1  Trousseau. 


IRREGULAR    GOUT.  2/3 

suffer.  Cramps  have  long  been  rightly  ascribed  to  gouty  influence 
in  many  cases.  I  have  long  believed  that  the  cramps  which 
accompany  the  cachexia  associated  with  granular  disease  of  the 
kidney  were  related  to  gouty  taint  in  certain  instances.  I  first 
learned  to  inquire  for  this  symptom  from  reading  Dr.  George 
Johnson's  lectures  on  the  subject  of  granular  kidney. 

Wandering  pains  have  been  noted  in  various  parts,  and  in  the 
subjects  of  gout  which  does  not  regularly  develop  itself  some 
fresh  ache  or  disagreeable  symptom  crops  up  almost  every  Week ; 
and  thus  patients  complain  of  gout  "  flying  about/'  and  they  do 
not  know  where  a  fresh  precipitation  or  petty  outbreak  may  occur. 

Patients  thus  affected  commonly  know  by  their  general  sensa- 
tions on  awaking  in  the  morning  whether  they  are  likely  to  suffer 
from  any  special  manifestation  during  the  day.  Such  manifesta- 
tions occur  very  frequently  during  the  night,  and  are  first  dis- 
covered early  in  the  morning.  Sometimes  there  are  observed 
fleeting  pains,  twinges,  in  one  or  more  joints  of  the  fingers  and 
toes. 

So-called  muscular  rheumatism  appears  to  occur  with  marked 
frequency  in  persons  of  gouty  tendency.  In  many  of  these  cases 
I  have  observed  that,  as  happens  so  commonly  in  gouty  affections, 
the  pains  are  only  discovered  in  the  night,  or  on  the  morning 
following  an  exposure  to  damp  which  occurred,  perhaps,  many 
hours  before  on  the  previous  day.  The  patient  retires  to  bed  in 
perfect  comfort,  and  awakes  in  the  early  morning  to  find  himself 
racked  with  the  characteristic  torture. 

Lumbar  pain  in  the  mornings,  passing  off  in  an  hour  or  two,  is 
occasionally  noted  without  any  obvious  renal  disturbance.  Uratic 
deposits  in  lymph-spaces  may  be  the  exciting  cause  of  some  of  the 
pains  just  described. 

A  frequently  recurring  minor  trouble  in  some  goutily  disposed 
persons  is  a  painful  follicular  inflammation  in  the  ala  of  the  nose. 
An  indolent  furuncle  forms,  which  does  not  proceed  to  suppurate. 
It  lasts  for  a  few  days  and  then  resolves.  The  pain  is  consider- 
able and  annoying.  The  inflammation  returns  again  and  again 
in  the  same  spot,  or  very  near  it.  Allusion  will  subsequently  be 
made  to  the  flushings  of  the  face  and  of  the  nose  observed  in  some 
gouty  persons.  Gradual  thickening  of  the  integuments  of  the 
end  of  the  nose  is  a  well-recognized  change  in  the  subjects  of 
chronic  gout. 

Tinglings  in  the  hands  and  feet  are  often  complained  of  by 
gouty  persons,  the  sensation  being  described  as  "  pins  and 
needles."     Women  about   the  time  of  the  menopause   are  sub- 

s 


274  CLINICAL   VARIETIES    OF    GOUT. 

ject  to  this.1  Treatment  for  imperfectly  developed  gout  is  often 
effectual  to  remove  these.  There  may  be  in  these  cases  some 
degree  of  perineuritis,  excited  by  uratic  stasis. 

Episcleritis  is  sometimes  noted,  and  may  become  persistent 
without  causing  much  annoyance.  Other  troubles  affecting  the 
eyes  in  gouty  persons  have  been  noted  previously.  Iritis  may 
occur.  To  determine  its  significance,  regard  must  be  had  to  the 
personal  and  family  history  as  to  true  gout,  since  rheumatism  may 
be,  perhaps,  the  excitant  constitutional  cause.  The  goutily  dis- 
posed seem  especially  obnoxious  to  the  poison  of  gonorrhoea,  and 
are  more  than  others  apt  to  suffer  from  sclerotitis.  Conjunctival 
haemorrhages  may  occur  spontaneously  in  the  gouty. 

Irregular  gout,  as  involving  the  respiratory  system,  has  been 
described  in  Chapter  iv.,  where  I  have  treated  of  bronchitis  and 
pneumonia.  Asthma,  as  dependent  on  gout,  is  discussed  in  Chapter 
x.  p.  2 1 7.  I  shall  have  again  to  refer  to  these  disorders  in  treating 
of  retrocedent  gout.  Gouty  tonsillitis,  commonly  one-sided,  is  met 
with,  and  is  apt  to  be  very  painful.  Catarrh  of  the  fauces  and 
pharynx  is  apt  to  become  chronic,  and  to  excite  severe  hacking 
cough.  Stokes  noted  the  sighing  respiration  of  undeveloped 
gout. 

Irregular  gouty  manifestations  of  the  alimentary  system  have 
also  been  referred  to.  Deep-seated  pains  in  the  tongue  are  to  be 
noted,  lasting  from  a  few  hours  to  two  or  three  days. 

Xerostomia. — I  saw  on  several  occasions  a  widow  lady,  over 
sixty,  in  whom  extreme  dryness  of  the  tongue  and  mouth,  lasting 
for  months,  proved  one  amongst  many  plain  indications  of  a  gouty 
habit.  True  gout  came  out  in  the  great-toe  some  years  later. 
Dr.  Hadden's  patient  with  dry  mouth,  whom  I  saw  at  the  Clinical 
Society's  meeting,  appeared  to  me  to  afford  an  example  of  incom- 
plete gouty  habit.  She  had  bad  shingles  and  facial  erysipelas.2 
A  granular  condition  of  the  pharynx  is  very  common,  causing 
chronic  gouty  sore-throat,  with  difficult  expectoration  of  tough, 
greyish,  pearly  mucus.  In  such  cases  snoring  is  very  frequently 
observed  during  sleep,  sometimes  of  great  intensity,  and  aggravat- 

1  "  It  is  probable  that  the  decussations  of  the  sensory  nerves  of  the  hands  and 
feet  are  high  up  within  the  cranium,  and  not  in  the  cord,  as  is  the  case  with  those 
of  the  upper  arms  and  thighs  ;  for,  the  former,  being  tactile  and  executive  instru- 
ments, must  have  both  their  special  motor  and  sensory  centres  within  the  encephalon. 
Thus,  numbness  as  well  as  motor  palsy  beginning  in  both  hands  or  in  both  feet  is  a 
sign  of  intracranial  disease.  In  like  manner  symmetrical  gout  of  the  hands,  and 
symmetrical  skin-affections  like  purpura  and  psoriasis  palmaris,  are  associated  with 
trophic  nervous  debility  of  centric  origin.  The  hot  palms  in  fevers  and  in  various 
neuroses  belong  also  to  this  class  of  symptoms." — Lay  cock. 

2  Clin.  Soc.  Trans.,  vol.  xxi.,  1888,  p.  176. 


IRREGULAR    GOUT.       CESOPHAGISMUS.  275 

ing  the  congested  state  of  the  fauces.  In  such  instances  it  is 
not  due  to  dorsal  decubitus  only. 

CEsophagismus. — Spasmodic  condition  of  the  oesophagus  has 
been  distinctly  proved  to  occur  as  an  irregular  form  of  gout. 
Brinton  first  described  this,1  and  Garrod  mentions  an  instance  of 
it.  Dr.  Moorhead,  of  Weymouth,  recorded  a  well-marked  example 
in  a  man  over  sixty  years  of  age.2  I  have  met  with  one  or  two 
examples.  Gouty  oesophagismus  may  prove  very  severe,  and  was 
so  far  rebellious  in  one  case  which  I  conceive  was  probably  of  this 
nature,  recorded  by  Mr.  Henry  Power,  as  to  prove  fatal.3  Post- 
mortem  evidence  was  negative  as  to  any  structural  disease  in  the 
gullet  or  stomach,  or,  indeed,  in  any  part  of  the  body.  Painful 
and  spasmodic  dysphagia  may  be  due  to  a  gouty  state  of  the  root 
of  the  tongue  and  pharynx,  which  condition  I  once  met  with  in  a 
retired  army-surgeon.  There  was  severe  pain  and  spasm  in  the 
left  side  of  the  pharynx  in  this  case,  and  the  attacks  occurred  at 
intervals  for  two  months.  Du  Hahn  related  a  case  of  this  kind, 
in  which  relief  came  with  onset  of  gout  in  the  hand.4  Hiccup 
has  been  noted  by  W.  Gairdner.5 

Much  discussion  has  arisen  on  the  subject  of  gout  in  the 
stomach  and  intestinal  tract.  Some  authors  deny  the  occurrence 
of  such  disorders.  I  am  convinced  of  their  existence,  and  shall 
discuss  them  under  the  head  of  visceral  gout.  Here,  it  will  suffice 
to  mention,  as  irregular  gouty  manifestations  in  these  organs, 
dyspepsia  with  anorexia,  nausea,  vomiting,  heartburn,  flatulency, 
and  gastrodynia.  Pain  is  rarely  met  with  unattended  with  pyrosis, 
acidity,  or  flatulency.  The  bowels  are  irregular ;  sometimes  cos- 
tiveness  prevails,  at  others  severe  diarrhoea  may  occur.6  By 
metastasis,  as  will  be  shown,  the  stomach  may  be  gravely  involved 
in  gouty  inflammation. 

All  the  disorders  just  enumerated  may  be  scattered  by  the 
onset  of  an  acute  articular  attack. 

A  severe  form  of  colic  (colica  arthritica)  is  sometimes  induced 
as  a  form  of  irregular  gout,  which  I  shall  discuss  under  the  head 
of  Visceral  Gout.  The  belly  is  often  flatulent  before  a  gouty 
paroxysm,  and  the  bowels  hard  to  purge.  Haemorrhoids  may 
occur  in  association  with  constipation  and  with  portal  venous  con- 

1  Lancet,  January  6,  1866,  p.  2.         .  -  Lancet,  July  23,  1881,  p.  164. 

3  Lancet,  March  10,  1866. 

4  Quoted  by  van  Swieten  in  his  Commentaries  on  Boerhaave's  Aphorisms,  vol.  xiii. 
p.  60,  1765.  fi  Op.  cit.,  p.  68. 

6  Todd  described  cases  in  which  a  considerable  discharge  of  mucus  coloured  with 
bile  occurred  for  two  or  three  days  as  a  variety  of  gouty  exacerbation  which  afforded 
great  relief. 


276  CLINICAL    VARIETIES    OF    GOUT. 

gestion,  which  are  frequent  in  gouty  subjects.  They  are  often 
hereditary.  Pruritus  ani  is  another  allied  symptom.  Varix  in 
the  legs  is  not  uncommon,  and  may  be  met  with  in  obese  gouty 
subjects.  Enlargement  of  veins  is  noticed  in  connection  with 
acute  gouty  attacks  in  any  part.  Severe  anaemia  may  be  caused 
by  bleeding  from  piles,  and  in  this  condition  acute  attacks  of  gout 
may  supervene,  of  which  I  have  seen  several  examples.  The 
urinary  system  suffers  markedly  from  irregular  manifestations  of 
gout.  The  special  implication  of  the  kidneys  has  been  already 
discussed  at  length,  and  the  tendency  for  progressive  interstitial 
nephritis  to  set  in  as  gout  becomes  chronic,  is  now  fully  recog- 
nized. In  the  present  connection  I  would  allude  to  the  frequent 
occurrence  of  nephritic  complaints  in  the  form  of  gravel,  renal 
colic,  and  vesical  calculi.  These  fits  of  gravel  and  colic  may 
alternate  with  articular  gout,  or  may  appear  in  members  of  gouty 
families  who  do  not  present  as  yet,  or  may  never  present,  signs 
of  active  gout  in  their  joints.  The  connection  is,  however,  very 
intimate  between  these  two  states,  and  may  affect  both  sexes. 
Renal  calculi  may  form  in  persons  long  before  any  articular  gout 
supervenes.  I  by  no  means  infer  from  this  fact  that  all  subjects 
of  renal  concretions  are  indisputably  gouty.  This  is  certainly 
not  the  case. 

As  already  noted,  gout  may  fall  on  the  mucous  membrane  of 
the  bladder,  causing  recurring  haemorrhage  or  severe  cystitis.1 
By  metastasis,  eczema  of  the  skin  may  pass  to  the  bladder  and 
suddenly  induce  cystitis.  In  elderly  men  prostatic  enlargement 
may  supervene,  and  add  to  the  difficulties  of  the  inflamed  bladder. 
Very  free  haemorrhage  may  occur  from  the  bladder  in  irregular 
gout.  The  urethra  may  be  the  seat  of  gouty  inflammation,  simu- 
lating very  closely  an  ordinary  gonorrhoea,  with  scalding  pain  and 
purulent  discharge.  Gouty  orchitis  will  be  referred  to  subse- 
quently. I  suspect  that  ovaritis  may  occur  as  a  result  of 
irregular  gout.  I  have  no  experience  of  it,  and  gynaecologists 
are  not  in  accord  as  to  its  dependence  on  this  state.  If  the 
disorders  of  the  uterus  and  its  appendages  were  studied  more 
particularly  with  reference  to  diathetic  conditions,  I  am  of  opinion 
that  some  new  chapters  in  their  pathology  might  be  written.  At 
the  present  time,  this  large  subject  is,  perhaps,  regarded  in  too 
mechanical  and  surgical  an  aspect,  and,  owing  to  the  prevailing 
tendency  to  specialization  in  practice,  the  general  physician  is 
not  brought  much  in  contact  with  it.  I  believe  that  expression 
of  the  gouty  habit  may  be  sometimes  met  with  in  women  in  the 
1   Vide  Clin.  Lect.  Urinary  Diseases,  R.  B.  Todd,  1857,  cases  related,  p.  357. 


GOUTY    PSYCHOPATHIA.  277 

form  of  uterine  congestions  with  metrorrhagia,  dysmenorrhoea, 
and  leucorrhoea,1  and  Dr.  Priestley  gives  me  his  experience  to  the 
effect,  that  women  of  gouty  heritage  are  more  apt  than  others 
to  suffer  from  chronic  metritis,  chronic  capsular  and  interstitial 
ovaritis,  and  menorrhagia.  Dysmenorrhoea  and  amenorrhoea  due 
to  plethoric  states  are  also  recognized  in  this  connection.  In  all 
such  cases  great  benefit  is  derived  from  anti-gouty  medication, 
and  especially  from  drugs  which  promote  a  free  circulation 
through  the  portal  vein.2  Elderly  males,  the  subject  of  irregular 
gout,  are  sometimes  much  troubled  by  priapism,  occurring  in  the 
night.  In  these  cases  there  is  usually  found  an  ill-expressed  gouty 
condition  with  acid  urine.      There  may  be  no  erotic  feelings. 

Glycosuria,  as  a  frequently  associated  state,  has  already  been 
described. 

The  liver  presents  symptoms  of  disturbance  in  irregular  gout. 
Biliary  lithiasis  with  colic  is  not  uncommon,  especially  in  women 
of  gouty  families.  Catarrh  of  the  bile-ducts  has  been  observed. 
Murchison  related  two  cases  in  gouty  men,  under  forty  years  of 
age,  who  had  vomiting,  wasting,  jaundice,3  and  hepatic  enlarge- 
ment from  this  cause.  The  cases  simulated  cancer,  but  subsided 
under  treatment.  Occasional  engorgements  of  the  liver,  followed 
by  diarrhoea,  have  been  noted  in  gouty  persons. 

In  respect  of  the  cutaneous  system,  any  of  the  various  skin- 
diseases  described  in  Chapter  xvi.  may  be  met  with — eczema, 
psoriasis,  urticaria,  and  pruritus  being  the  most  frequent  mani- 
festations. 

The  circulatory  system  is  markedly  involved,  and,  thus,  may 
occur  palpitations,  cardiac  and  arterial,  irregular  pulsations,  syn- 
cope, and  pseudo-angina  pectoris.  Arterial  spasm  in  various 
parts,  such  as  "  dead  fingers,"  or  flushings,  may  be  met  with. 

The  nervous  system  is  variously,  and  sometimes  profoundly, 
influenced  by  the  gouty  state.  Many  morbid  conditions  thus 
arise,  and  have  been  discussed  in  Chapter  x. 

Varieties  of  headache,  hemicrania,  neuralgia,  neuritis,  vertigo, 
tinnitus  aurium,  and  vague,  sometimes  fugitive,  pains  may  be 
met  with. 

Gouty  Psyeopathia. — The  psychical  conditions  are  of  infinite 
variety.  Irascibility,  "  touchiness "  of  temper,  capriciousness, 
morbid  forebodings,  miserable  mental  introspection,  hypochon- 
driasis, neuromimesis,   melancholia,   and  even  suicidal  tendency, 

1  Vide  Art.  "  Goutte,''  H.  Rendu,  Diet.  Encyclop.  des  Sciences  Med.,  p.  129. 

2  Vide  Inflam.  of  Uterus,  Reynolds'  Syst.  Med.,  vol.  v.  p.  736. 

3  Op.  cit.,  p.  156. 


278  CLINICAL    VARIETIES    OF    GOUT. 

have  all  been  carefully  noted  as  expressions  of  irregular  gouty 
states  of  the  system  (melancholia  arthritica  of  Musgrave).  A  fit 
of  violent  rage  or  passion  may  be  a  solitary  expression  of,  or 
possibly  a  substitution  for,  an  attack  of  regular  gout ;  so,  too, 
some  transient  mental  derangement. 

The  mental  element  in  persons  of  gouty  habit  is  a  very  note- 
worthy factor,  and  a  due  consideration  of  it  is  of  high  importance 
for  successful  treatment  of  many  cases.1  Mental  energy  may 
never  safely  run  in  excess  of  other  bodily  forces,  and  many  persons 
become  gouty  because  the  former  outruns  the  latter.  This  is  often 
exemplified  in  the  cases  of  men  who  are  placed  by  various  callings 
under  conditions  of  life  in  which  they  are  ill-fitted  to  act  and  de- 
velop their  peculiar  energies.  The  man  who  is  adapted  by  his 
muscularity  and  vigorous  circulation  for  an  active  outdoor  life  is 
unfavourably  circumstanced,  if  he  must  needs  support  himself  by 
sedentary  occupation  amidst  town-surroundings.  Defect  of  aera- 
tion and  insufficient  muscular  energy  will  tend  to  induce  a  gouty 
state,  and  no  less  will  the  tendency  be  maintained  by  undue 
mental  energy,  which  now  becomes  the  channel  for  his  enforced 
activity.  It  is  the  case  of  "  the  square  peg  in  the  round  hole." 
There  ensues  a  battle  of  forces ;  the  restrained  muscular  energies 
evoke  vicious  distempers,  amongst  which  comes  out  urichsemia 
(acquired  gout),  and  the  mental  phases  are  apt  to  become  morbid, 
and,  in  turn,  injuriously  influenced  by  the  onset  of  the  gouty  state. 

Insomnia  is  sometimes  a  manifestation  of  irregular  gout,2  and 
has  not  received  sufficient  recognition.  The  rude  interruption 
of  sleep,  which  is  common  in  an  acute  gouty  paroxysm  during 
the  earlier  hours  of  the  morning,  affords  a  type  on  which 
the  less-marked  and  minor  symptoms  of  gouty  insomnia  are 
founded. 

The  simplest  form  of  sleeplessness  which  occurs  in  persons 
goutily  disposed  is  due,  in  most  instances,  to  acid  or  fermentative 
dyspepsia.  The  earliest  and  best  account  of  this  with  which  I  am 
acquainted  was  given  by  Cullen,3  who  remarked  that  "  persons  who 
labour  under  a  weakness  of  the  stomach,  as  I  have  done  for  a  great 
number  of  years  past,  know  that  certain  foods,  without  their  being 
conscious  of  it,  prevent  their  sleeping.  So,  I  have  been  awaked 
a  hundred  times  at  two  o'clock  in  the  morning,  when  I  did  not 

1  Vide  contribution  on  this  subject  by  Dr.   Mortimer  Granville.     Lancet,  vol.  i. 
p.  676,  1881. 

2  On  Insomnia  and  other  Troubles  connected  with  Sleep  in  Persons  of  Gouty  Dis- 
position.    By  Dyce  Duckworth.     Brain,  July  188 1. 

3  Works,  edited  by  Thomson,  vol.  i.  p.  127.  Edin.,  1827.  Cullen  did  not  himself 
connect  this  symptom  with  gouty  tendency. 


INSOMNIA.  2/9 

feel  any  particular  impression ;  but  I  knew  that  I  had  been 
awakened  by  an  irregular  operation  in  that  organ,  and  I  have 
then  recollected  what  I  took  at  dinner,  which  was  the  cause  of 
it."  This  sleeplessness  is  often  caused  by  some  particular  article 
of  diet  which  the  sufferer  digests  imperfectly,  or  may  be  due  to 
excess  of  wine  or  mixing  of  various  liquors.  Very  often  fatty  or 
saccharine  matters  in  excess,  or  mixture  of  fruit  and  wine,  may 
cause  this  dyspepsia.  There  may  be  no  overt  symptoms  of  dys- 
pepsia, but  a  simple  excess  in  eating,  or  a  single  article  of  diet 
which  is  digested  with  difficulty,  may  so  disturb  the  cerebral 
circulation  that  sleep  is  interrupted  and  suspended  for  a  time.  I 
described  these  symptoms  in  a  paper  which  was  published  in 
1873,  and  stated  my  belief  that  they  were  more  common  in 
persons  who  had  tendency  to  gout.1 

The  dyspepsia  probably  arises  from  faults  not  only  in  the 
stomach,  but  in  the  duodenum  and  upper  part  of  the  small 
intestine. 

Dr.  Murchison  described  this  form  of  sleeplessness,  and  attri- 
buted it  to  the  hepatic  derangement  which  induced  lithasmia  and 
other  symptoms  of  gout.2  A  very  noteworthy  point  about  such 
cases  is  the  particular  time  at  which  the  insomnia  begins.  The 
sufferer  retires  to  rest  feeling  quite  •  well,  and  free  from  any 
discomfort.  But  his  sleep  is  rudely  interrupted,  it  may  be  by 
some  unpleasant  dream,  and  he  is  at  once  aware  of  uneasi- 
ness in  the  stomach,  has  heartburn  or  flatulence,  and  perhaps 
nausea. 

If  nothing  be  done,  the  patient  will  lie  awake  with  throbbing 
head  and  active  flow  of  thoughts  for  an  hour  or  two,  when  sleep 
will  return.  On  rising  the  next  morning,  he  will  probably  ex- 
perience some  headache  and  find  his  appetite  diminished.  An 
attack  of  hemicrania  may  perhaps  render  the  next  day  miserable 
for  him.  Such  a  form  of  dyspepsia  is  plainly  a  manifestation  of 
a  gouty  tendency. 

An  incapacity  to  digest  certain  definite  articles  of  food  is  very 
marked  in  the  gouty,  and  is  not  unfrequently  one  of  the  earliest 
tokens  of  the  disorder.  In  youth  there  may  be  vigorous  digestion 
for  all  kinds  of  food,  but  as  the  third  decade  is  approached,  the 
inability  declares  itself. 

It  may  be  objected  that  there  is  nothing  very  remarkable  about 
such  symptoms,  and  that  they  are  common  enough.     The  charac- 

1  On  Certain  Forms  of  Sleeplessness.    Brit.  Med.  Journal,  December  27,   1873, 
and  republished  by  Longmans,  1874. 

2  Op.  cit.,  2nd  edit.,  p.  590,  1877. 


280  CLINICAL    VARIETIES    OF    GOUT. 

teristic  part  of  the  disturbance  is  the  special  digestive  inadequacy 
at  a  very  definite  period.  If  we  suppose  that  this  enfeeblement 
is  due  to  the  taking  of  a  full  meal  late  in  the  day,  and  that  the 
digestive  powers  would  be  adequate  to  dispose  comfortably  of  the 
same  if  taken  early — which  is  fairly  conceivable — we  have  no  means 
of  knowing  whether  sleep,  were  it  sought  after  some  hours,  would 
be  interrupted  under  such  circumstances.  The  fact  remains  that, 
in  persons  of  gouty  constitution,  sleep  is  apt  to  be  disturbed  by 
the  irritation  arising  from  their  peculiar  digestive  incapacity,  and 
at  a  definite  period  of  that  process.  An  interval  of  four  or  five 
hours  occurs  between  the  meal  and  the  awaking,  the  patient  being 
disturbed  within  about  two  hours  of  retiring  to  bed.  This  is  the 
time  at  which  attacks  of  gout  are  especially  liable  to  come  on, 
and  the  sufferer  is  suddenly  awakened  with  pain  in  the  affected 
part.  In  this  case,  as  usually  in  that  of  gouty  dyspeptic  insomnia, 
the  patient  has  retired  to  bed  feeling  comfortable  and  in  his 
ordinary  health. 

Other  forms  of  gouty  trouble  manifest  themselves  not  uncom- 
monly in  the  early  hours  of  the  morning.  Thus,  attacks  of  bron- 
chitis with  asthmatic  dyspncea  sometimes  replace,  or  alternate 
with,  regular  onsets  of  gout,  and  the  paroxysms  of  asthma  are 
very  prone  to  begin  and  to  disturb  the  patient  after  midnight. 

Not  only  is  sleep  thus  interrupted,  but  other  peculiar  symptoms 
are  met  with  in  those  of  gouty  proclivity  in  connection  with  the 
sleeping  hours.  It  has  been  observed  that  in  cases  where  a  regu- 
lar attack  is  expected,  but  does  not  supervene,  sleep  is  abruptly 
broken  some  hours  before  the  usual  time  of  waking,  and  does  not 
return.  Some  horrible  dream  may  lead  to  this,  and  the  same 
occurrence  may  take  place  for  several  mornings  in  succession. 
Scudamore  relates  two  cases  where  sleep  was  merely  disturbed  by 
uneasy  dreams,  and  gout  was  established  in  the  joints  on  awaking 
in  the  morning. 

Startings  and  shouting  have  been  noted,  associated,  or  not, 
with  the  dyspepsia  preceding  or  accompanying  gout.  Grinding 
of  the  teeth  during  sleep  is  a  symptom  met  with  in  those  who 
are  gouty.  I  have  collected  several  examples  of  it,  and  Dr.  Donkin 
likewise  directed  attention  to  some  well-marked  cases  which  occurred 
in  the  family  of  parents  who  were  both  gouty.1  In  this  family 
there  was  also  history  of  somnambulism.  The  father,  a  gouty 
man,  was  a  habitual  somnambulist  in  early  life,  and  occasionally 
in  later  years  walked  about  in  his  sleep.  The  mother  ground  her 
teeth  at  night  for  many  years.      She  was  of  gouty  parentage,  as 

1  Brit.  Med.  Journal,  February  21,  1880,  p.  279. 


INSOMNIA.  28l 

already  stated,  but  had  had  no  overt  gout  herself.  The  whole 
family,  of  eight  children,  ground  their  teeth  almost  incessantly  at 
night.  Most  of  them  were  extremely  "  nervous,"  and  walked  in 
their  sleep.      They  also  talked  during  sleep. 

I  have  record  of  one  case  in  which  there  is  both  tooth-grind- 
ing and  occasional  somnambulism,  the  mother  and  maternal  grand- 
father being  distinctly  gouty.  Nightmare  and  startings  of  the 
limbs  have  been  observed  with  some  frequency  in  persons  goutily 
disposed. 

In  connection  with  the  subject  of  insomnia  in  the  gouty,  may 
be  noted  the  fact  that  many  of  the  special  determinations  of  the 
malady  take  place  during  the  night,  whether  the  sleep  be  dis- 
turbed or  not.  The  patient  retires  to  bed  feeling  in  his  usual 
health,  but  on  awaking  in  the  morning,  he  discovers  at  once 
some  new  phase  of  his  malady ;  it  may  be  muscular  pain  or 
stiffness,  angina  of  the  fauces,  the  beginning  of  a  hemicrania, 
or  more  or  less  severe  pain  in  some  joint  or  adjacent  texture, 
such  as  a  stiff  neck,  lumbago,  or  a  burning  phalangeal  joint. 
These  troubles,  or  some  of  them,  have  come  on  in  the  night,  but 
have  not  been  sufficient  to  disturb  sleep.  Cramps  in  the  calves 
of  the  legs  are  especially  prone  to  vex  gouty  persons  at  night, 
and  sometimes  for  several  nights  precede  a  severe  attack. 

The  fact  that  not  only  acute  attacks  of  gout  are  apt  to  super- 
vene during  the  hours  allotted  to  sleep,  but  that  other  less  severe 
gouty  manifestations  likewise  occur  during  the  night,  or  are 
found  to  have  come  on  at  that  period,  is  one  amongst  many  which 
may  be  appealed  to  in  proof  of  the  neurotic  element  in  this  malady, 
for  it  has  this  peculiarity  in  common  with  several  other  morbid 
affections  which  are  conceded  on  all  hands  to  be  distinct  neuroses. 
Thus,  epilepsy,  neuralgia,  spasmodic  asthma,  gastralgia,  angina 
pectoris,  laryngismus  stridulus,  and  hemicrania  are  all  prone  to 
disturb  sufferers  during  the  early  hours  of  sleep,  or  immediately 
on  awaking.  In  all  these  cases  we  have  to  seek  for  a  cause 
which  determines  these  outbreaks  with  such  marked  constancy  in 
connection  with  the  sleeping  state. 

From  the  nature  of  the  case,  we  have  but  scant  knowledge  of 
most  of  the  physiological  conditions  which  occur  during  sleep. 
It  is,  however,  known  that  the  bodily  temperature  falls  both  in 
health,  and  in  most,  if  not  in  all,  morbid  states,  between  the 
hours  of  midnight  and  six  o'clock  in  the  morning.  Some  observers 
have  noted  the  minimum  temperature  to  occur  between  eleven 
p.m.  and  three  A.M.,  and  although  the  fall  does  not  amount  to 
more  than  one  or  one  and  a  half  degree,  it  has  nevertheless  a 


252  CLINICAL    VARIETIES    OF    GOUT. 

distinct  significance  as  indicating  some  direct  nervous  influence 
on  heat-production.  Certainly  this  constant  and  normal  reduc- 
tion of  temperature  is  independent  of  removal  of  clothing  and 
abstraction  of  heat  by  bedclothes.  Again,  the  subjective  sensa- 
tion of  chilliness  about  three  o'clock  in  the  morning  is  familiar  to 
all  who  sit  up  at  night,  and  at  that  period,  too,  there  is  a  maxi- 
mum of  weariness  and  exhaustion,  and  the  greatest  instinctive 
demand  for  sleep.  Even  the  worst  sleepers  will  commonly  fall 
asleep  at  this  hour,  although  they  may  have  been  miserably  wake- 
ful and  restless  previously. 

There  is  also  a  greater  susceptibility  to  cold  at  night-time. 
The  "  middle  watch"  is  the  most  trying  in  all  respects.  This  is 
the  period  of  the  greatest  exhaustion  of  the  whole  nervous  system, 
the  automatic  cerebral  activity  ceases,  and  sleep  is  "  the  diastole 
of  the  cerebral  beat."  l  As  the  old  writers  put  it,  the  "  brain- 
power is  lowered  "  in  sleep. 

Digestion  is  feebler  during  sleep  than  in  the  waking  state, 
and  so,  too,  is  the  action  of  the  heart,  and  both  the  circulatory 
and  respiratory  acts  are  reduced  in  force  and  frequency.  With 
the  exception  of  the  cutaneous  functions,  perhaps  all  others  are 
at  rest  as  far  as  possible. 

Sleep  is  more  profound  in  the  earlier  hours  of  night,  and 
gradually  becomes  less  so  towards  morning. 

It  seems  impossible,  in  view  of  the  foregoing  considerations, 
not  to  find  some  reasons  for  the  marked  tendency  towards  irre- 
gular outbreak  of  nervous  energy  during  the  hours  when  so  many 
cyclical  processes  are  modified  or  interrupted. 

In  perfect  health,  and  in  persons  not  neurotically  disposed,  no 
irregular  effects  ensue ;  but  in  morbid  states  and  in  the  neuroses, 
the  hours  of  sleep  are  particularly  those  in  which  we  might  expect 
some  outbreak  or  irregularity,  and,  as  a  matter  of  experience,  we 
find  such  to  be  the  case  in  marked  degree. 

The  anagmia  of  the  brain  in  sleep  may  have  some  influence  in 
determining  some  of  these  disorders ;  but  this  condition  is  not 
believed  to  be  the  cause  of  sleep,  but  only  an  effect  or  concomitant 
of  it.  In  the  cases  of  dyspepsia  already  considered,  there  is  a 
manifest  source  of  irritation  at  a  distance ;  but  the  peculiarity 
here  is  that  it  only  becomes  potent  at  a  definite  time  to  disturb 
sleep,  either  by  the  generation  of  some  special  morbid  product  in 
the  course  of  digestion,  which  may  act  from  a  distance  reflexly, 
or  may  enter  the  circulation  and  rouse  the  higher  centres.  These 
centres  may,  during  the  temporary  depression  due  to  sleep,  be 
1  Foster,  Text-Book  of  Physiology,  p.  573,  1st  edit. 


INSOMNIA.       INCUBUS.  283 

more  than  at  other  periods  specially  irritable,  and  in  the  cases  of 
such  persons  as  are  neurotically  disposed,  they  are  almost  cer- 
tainly in  less  stable  condition  than  are  those  of  the  healthy. 

The  direct  influence  of  an  excess  of  uric  acid  circulating  in 
the  blood  can  hardly  be  lost  sight  of  in  connection  with  gouty 
insomnia.  It  is  well-recognized  that  such  excess  is  frequently 
present  without  the  induction  of  any  overt  disturbance,  nervous 
or  otherwise,  in  persons  who  have  no  gouty  proclivity  ;  but  in 
any  case  of  true  gouty  habit  we  must  not  ignore  the  influence  of 
what,  when  in  excess,  is  a  real  poison  in  the  circulation. 

The  special  determinations  of  gout  to  certain  parts  are  in- 
separably connected  with  excess  of  uric  acid  in  such  parts,  and 
thus  we  may  fairly  conceive  that  some  of  the  nervous  symptoms 
which  occur  in  the  gouty  owe  their  cause  to  irritation  of  nervous 
tissue  by  this  peccant  matter.  Insomnia  may  well  be  one  symp- 
tom due  to  this  irritation. 

It  is  to  be  noted  that  these  troubles  in  connection  with  the 
sleeping  state  are  not  only  met  with  when  the  subjects  of  them 
are  in  a  very  gouty  condition,  or  as  precursors  of  outbursts  of 
gout  in  the  arthritic  form  ;  they  form  part  of  the  many  minor 
affections  to  which  persons  goutily  disposed  are  sometimes  liable. 
Gout,  like  other  maladies,  has  varying  significance  in  the  par- 
ticular individual  affected,  and  the  fact  of  goutiness  so  far  modi- 
fies the  constitution  or  bodily  habit  of  the  patient.  Thus,  many 
sufferers  have  no  troubles  connected  with  the  sleeping  state,  just 
as  many  have  no  urinary  difficulties,  no  hemicrania,  and  no  tophi. 

The  fact  that  attacks  of  gout  set  in  violently  by  day,  and  not 
by  night,  in  no  degree  minimizes  the  value  and  importance  of 
accurate  observations  on  the  symptoms  presented  during  sleep 
in  persons  disposed  to  gout.  We  must  not  fail  to  recognize  their 
special  significance  when  we  meet  with  them. 

Many  sufferers  are  good  sleepers  in  the  intervals  between 
severe  attacks,  and  many  others  can  secure  good  nights  with 
due  precautions  as  to  diet  and  other  habits.  The  particular 
insomnia  described  is  rather  the  indication  of  the  gouty  habit 
than  a  particular  phase  of  either  acute  or  chronic  gout,  as  com- 
monly understood,  and  as  such  its  importance  has  not  hitherto 
been  clearly  signalized.  Its  recognition  is  necessary  for  the 
employment  of  the  only  line  of  treatment  that  can  truly  avail  to 
avert  it,  and  to  break  the  persistence  of  the  habit  on  which  it 
depends. 

Nightmare. — Sometimes,  nightmare  is  a  troublesome  symptom 
in  persons  of  gouty  habit.      Mr.  Thomas  Godfrey,  of  Mansfield, 


284  CLINICAL    VAPJETIES    OF    GOUT. 

has  recorded  a  noteworthy  instance  in  a  woman  of  gouty  inherit- 
ance, aged  seventy,  who  suffered  from  gouty  glycosuria  and 
eczema,  and  who  endured  terrible  nightmares  at  intervals  all  her 
life.  They  had  increased  greatly  of  late,  so  as  to  embitter  her 
existence. 

Retrocedent  or  Metastatic  Gout. 

When  an  acute  attack  of  articular  gout  suddenly  subsides,  and 
symptoms  of  disturbance  appear  in  other  and,  it  may  be,  distant 
parts  of  the  body,  there  is  said  to  be  retrocedence  or  metastasis 
of  the  process.1  This  is  a  form  or  variety  of  irregular  gout.  Some- 
times, these  phenomena  recur  rapidly  and  shift  their  positions  ; 
this  is  termed  "  flying  "  gout. 

Inasmuch  as  no  part  of  the  body  is  exempt,  or  likely  to  be 
exempt,  from  the  occurrence  of  gouty  processes,  the  situations  in 
which  metastatic  transference  may  be  witnessed  are  very  various. 
Hence,  some  forms  of  visceral  gout.  The  most  frequent  forms  of 
retrocedent  gout  are  those  in  which,  after  subsidence  in  a  joint, 
the  disease  alights  on  the  heart,  the  brain,  the  stomach  and  intes- 
tinal canal,  and  the  urinary  bladder.  Asthenic  gout  is  most  liable 
to  prove  metastatic,  but  sthenic  gout  will  sometimes,  under  de- 
pressing treatment,  shift  to  the  viscera. 

Retrocedent  quality  pertains  to  asthenic  varieties  of  gout,  and 
is  always  significant  of  atony  and  debility.  The  fact  that  the 
disease  is  anywhere  manifested  regularly  or  frankly  in  the  joints 
indicates  unlikelihood  of  metastasis.  The  subjects  of  flying  gout 
are  commonly  of  feeble  constitution  and  with  unstable  nervous 
system.  They  may  have  been  living  on  too  low  a  diet,  or  have 
undergone  too  prolonged  exertion. 

Cardiac  Gout— Retrocedence  to  the  Heart. — The  most  marked 
instances  of  this  particular  form  of  flying  gout  have  followed  on 
some  grave  imprudence  during  an  attack  in  a  joint.  Plunging  a 
gouty  foot  in  cold  water  or  in  snow  has  been  known  to  determine 
severe  cardiac  pain  within  a  few  minutes,  together  with  syncopal 
tendency  more  or  less  serious.  The  pulse  may  fall  in  frequency 
and  volume,  or  may,  with  absolute  cardiac  failure,  cease,  and  a 
fatal  issue  ensue.  Intense  spasm  is  thus  induced.  If  the  patient 
is  rallied  promptly,  violent  palpitation  may  ensue,  with  severe 
cardiac  pain  and  orthopncea.  Cough  and  expectoration  follow, 
and  many  days  may  elapse  before  the  balance  of  health  is 
restored. 

In  place  of  an  arthritic  attack,  after  premonitions  of  an  impend- 

1  This  peculiarity  was  noted  by  Galen  and  by  Aretseus. 


RETROCEDENT    GOUT.  285 

ing  paroxysm,  there  may  suddenly  supervene  syncope  with  great 
cardiac  depression,  ashy  pallor  of  body,  facial  anxiety,  and  pulse 
of  extreme  feebleness.  These  symptoms  may  last  for  some  hours, 
and  only  yield  to  active  stimulation,  while  several  days  may  elapse 
before  ordinary  health  is  recovered. 

Nocturnal  attacks  of  cardiac  pain  may  come  on  after  imperfect 
development  of  a  joint-attack,  and  dyspnoea  and  collapse  may  be 
associated  with  this. 

The  same  effects  have  been  known  to  follow  early  and  impru- 
dent exposure  to  cold  east  winds  when  recovering  from  arthritis, 
as  in  a  case  related  by  Garrod  in  a  man  get.  fifty  years.  The 
pain  was  violent  across  the  chest,  and  radiated  into  both  arms. 
The  pulse  was  feeble  and  intermittent.  There  was  no  overt 
cardiac  disease  and  no  pyrexia.  The  noxious  practice,  carried 
out  by  the  illustrious  Harvey  in  his  own  case,  of  plunging  a 
gouty  foot  or  part  into  cold  water  has  often  been  followed  by 
alarming  symptoms. 

It  is  probable  that  attacks  of  pseudo-angina  pectoris  are  of 
this  nature.  Some  of  the  cases  of  retrocedence  to  the  heart 
described  by  early  writers  would  now  be  explained  differently, 
and  be  referred  to  true  angina  with  structural  disease  of  the 
aorta  and  its  valves,  or  to  fatty  degeneration  of  the  cardiac  walls  ; 
while  others  were  plainly  examples  of  embolism  of  the  pulmonary 
artery,  due,  sometimes,  to  unrecognized  distal  gouty  phlebitis. 

Minor  attacks  of  flying  gout  affecting  the  heart  may  present 
no  further  symptom  than  feeble  action,  with  or  without  inter- 
mittency. 

It  is  probable  that  retrocedent  gout  alighting  on  the  heart  is 
never  directly  fatal,  unless  there  is  a  decided  degree  of  organic 
disease  present,  valvular  or  parietal,  or  both.1 

This  subject  will  again  engage  attention  under  the  head  of 
Visceral  Gout.  The  danger  is  greater  when  parietal  degeneration 
exists,  than  when  valvular  disease  is  present  without  damaged 
cardiac  muscle.  It  is  sometimes  difficult  to  determine  whether  the 
heart  or  the  stomach  is  more  affected  by  retrocedency.  Flatulent 
distension  of  the  latter  may  interfere  with  the  heart's  action,  and 
so  simulate  true  cardiac  spasm.  Disengagement  of  the  flatus 
commonly  affords  relief  in  these  cases.  A  feeble  heart  may 
thus  suffer  severely  and  give  rise  to  alarming  symptoms. 

Cerebral  Gout— Retrocedence  to  the  Brain. — Under  influences 
similar  to  those  just  described,  metastasis  may  occur  to  the 
encephalon. 

•    *   Vide  Stokes  on  Diseases  of  Heart  and  Aorta,  p.  359,  1854. 


286  CLINICAL   VARIETIES    OF    GOUT: 

The  symptoms  vary  in  degree,  from  mental  confusion  to  mania, 
and  are  sometimes  apoplectiform  with  coma.  Temporary  in- 
sanity is  well-recognized  as  sometimes  dependent  on  gouty  retro- 
cedence. 

With  relief  to  joint- symptoms,  indications  of  mental  failure 
supervene,  with  wandering  delirium.  Vertigo,  somnolence,  photo- 
phobia, and  disturbed  vision  may  be  noted  in  some  cases.  Apo- 
plectic strokes  may  suddenly  be  induced  with  every  classical 
symptom,  including  loss  of  consciousness,  coma,  stertorous  re- 
spiration, relaxation  of  limbs,  and  failure  of  the  sphincters. 
Hemiplegic  weakness  may  be  noted.  All  these  pass  off  under 
suitable  treatment  or  on  the  supervention  of  arthritis.  Such 
examples  resemble  in  all  points  the  gravest  case  of  cerebral 
haemorrhage,  and  sometimes  only  reveal  their  true  nature  by  a 
frank  outburst  of  gout  elsewhere,  and  by  the  complete  removal  of 
encephalic  symptoms  which  thereupon  ensues. 

Apoplexia  Arthritiea. — Many  noteworthy  examples  of  apoplectic 
seizure,  due  to  retrocedence  to  the  brain,  are  given  by  Scudamore. 
They  occurred  chiefly  in  plethoric  men  at  the  age  of  sixty.  Free 
venassection  proved  of  great  value,  and  paralytic  sequelae  were 
thus,  he  believed,  often  averted. 

I  do  not  believe  that  these  cases  are  now  so  frequently  met  with 
as  at  the  beginning  of  this  century.  Improvement  in  diet,  greater 
temperance  in  alcoholic  drinks,  the  use  of  diluents,  and  less  tight 
clothing,  probably  account  for  fewer  instances  at  the  present  time. 
In  no  such  case  can  it  be  believed  that  the  symptoms  depend  on 
cerebral  haemorrhage  ;  the  complete  subsequent  recovery  negatives 
this  idea.  The  diagnosis  as  to  this  may,  however,  be  impossible 
in  the  first  instance,  and  any  undue  tension  of  the  pulse  will  in 
any  such  case  justify  more  or  less  venisection  according  to  cir- 
cumstances. 

Gouty  Encephalopathy. — Less  grave  attacks  of  gouty  encephalo- 
pathy may  be  met  with  in  which  consciousness  is  not  lost,  but 
there  appear  signs  of  hemiplegic  paresis  in  the  face  or  limbs,  with 
aphasia,  thick  speech,  or  amnesia.  Severe  mental  emotions  or 
overwork  may  determine  such  accidents  in  the  presence  of  actively 
gouty  states  of  the  system.  The  essential  lesion  is  probably  that 
of  vascular  congestion. 

According  to  W.  Gairdner,  "  metastasis  to  the  head  is  the  most 
frequent  form  witnessed,  indicated  chiefly  by  a  kind  of  stupor,  in 
which  sight  and  hearing  are  preserved,  but  loss  of  appreciation  of 
surroundings,  of  recognition  of  persons,  or  place,  or  time  prevails. 
The  patient  does  not  recognize  members  of  his  own  family.      The 


CEREBRAL    GOUT.  287 

utterance  is  imperfect  or  lost.  He  seems  like  a  person  entranced  ; 
his  eyes  are  vacant  and  staring.  The  intelligence  is  impaired  ; 
actions  are  automatically  carried  out.  The  pulse  is  full  and  hard. 
This  condition  comes  on  gradually,  being  preceded  by  headache, 
somnolence  after  meals,  deficient  mental  alacrity  and  loss  of  interest 
in  matters  which  formerly  occupied  the  attention.  The  patient 
realizes  his  mental  failure  and  regrets  it."  x  Such  symptoms  may 
sometimes  betoken  a  degree  of  uraemia,  and  be  rather  of  this 
nature  than  true  expressions  of  metastatic  gout. 

Charcot  has  recorded  an  example  of  complete  aphasia  without 
loss  of  consciousness  or  any  paralysis  in  a  gouty  man,  which 
passed  off  on  supervention  of  access  of  gout  in  the  joints.  Sub- 
sequently, attacks  of  epilepsy  came  on,  preceded  by  a  sensory  aura 
in  the  little  finger,  limited  to  certain  groups  of  muscles  of  one  arm, 
with  aphasia,  indications  of  a  cortical  lesion.  The  aphasia  may  be 
intermittent,  and  has  been  known  to  persist  for  several  months. 

An  exact  diagnosis  of  the  conditions  prevailing  in  any  case  of 
gouty  encephalopathy  is  only  to  be  made  after  careful  examination 
of  the  various  organs  and  textures  of  the  patient.  Regard  must 
be  had  to  the  presence  of  a  gouty  habit,  or  to  history  of  remote 
or  recent  attacks.  If  there  be  indications  of  interstitial  nephritis, 
or  of  feeble  heart  and  atheromatous  arteries,  the  possibility  of 
uraemia  or  of  meningeal  or  cerebral  haemorrhage  must  be  borne 
in  mind. 

The  discrimination  is  sometimes  very  nice,  and  at  times  not 
immediately  possible.  The  age  of  the  patient  and  the  general 
tissue-state  aid  much  in  the  determination.  The  pulse  may  be 
tense  in  both  gouty  and  uraemic  encephalopathy.  It  may  be  very 
difficult  to  pronounce  at  once  for  epilepsy  or  for  uraemic  eclampsia 
in  a  goutily-disposed  person.  Both  sexes  may  thus  suffer,  but 
chiefly  males  after  middle  life. 

Allusion  has  already  been  made  to  gouty  mania,  melancholy, 
and  hypochondriasis,  also  to  hemicrania,  as  indications  of  cerebral 
gout. 

The  following  case,  which  I  saw  in  consultation  with  Dr.  Long- 
hurst,  exemplifies  some  of  the  features  of  cerebral  gout : — 

Mrs.  T.,  set.  sixty,  a  lady  of  large  frame,  obese,  and  generally  of  robust  consti- 
tution, was  seen,  first,  two  weeks  before  I  was  summoned,  suffering  from  "confusion 
in  the  head  "  and  flushing  of  the  face.  There  had  been  two  attacks  of  vertigo.  No 
headache.  The  heart's  action  was  rather  feeble,  no  murmurs  detectible.  The  pulse 
was  regular,  of  moderate  volume  and  full.  Arteries  not  hard.  An  apoplectic  fit 
being  feared,  the  patient  was  purged,  and  benefit  followed.     An  attack  of  sciatica 

1  Op.  cit.,  p.  yy. 


255  CLINICAL    VARIETIES    OF    GOUT. 

now  supervened,  which  was  treated  with  quinine.  The  day  before  I  saw  this  lady, 
she  had  had  many  visitors,  and  subsequently  fell  into  the  same  state  of  hebetude  and 
mental  oppression  as  at  first.  She  lay  prostrate,  with  her  eyelids  closed,  intolerant 
of  light,  and  was  confused  in  her  statements.  The  pupils  were  equal ;  no  arcus 
senilis  ;  conjunctivEe  suffused  ;  but  no  strabismus  existed,  nor  was  paresis  detect- 
ible  anywhere.  There  was  no  pain  in  any  part.  The  cardiac  sounds  were  clear  and 
feeble,  but  the  pulse  was  rather  firm.  The  urine  was  natural,  but  had  contained 
lithates  some  days  previously.  Some  years  ago  the  patient  had  suffered  from  similar 
attacks.  There  was  history  of  occasional  "  bilious  "  disorders.  An  encouraging 
prognosis  was  given. 

The  treatment  consisted  in  calomel  with  acetous  extract  of  colchicum,  and  a 
mixture  with  bromide  of  ammonium,  aromatic  spirit  of  ammonia,  and  compound  tinc- 
ture of  lavender.  Sinapisms  were  applied  to  the  nape,  and  hot  pediluvia  employed. 
Light  dietary.  Improvement  gradually  set  in  ;  but  complete  recovery  was  not 
attained  for  about  four  months.  Before  the  last  attack  this  patient  had  been  much 
busied  setting  her  house  in  order  on  her  return  from  the  country. 

I  am  indebted  to  Sir  Andrew  Clark  for  the  particulars  of  the 
following  cases  which  have  occurred  in  his  practice,  illustrating 
the  points  now  under  consideration. 

He  was  called  to  see  a  gentleman,  set.  fifty,  who  had  suffered  for  two  days  from 
incessant  and  irregular  cardiac  palpitation,  some  dyspnoea  and  recurrent  vertigo. 
No  objective  signs  of  disease  could  be  discovered  ;  but  in  the  history  of  his  habits,  in 
his  aspect,  and  in  the  disordered  condition  of  his  functions,  it  was  considered  that 
there  was  conclusive  evidence  of  a  gouty  state.  He  was  put  on  a  meagre  diet, 
ordered  to  take  a  dose  of  calomel  at  night,  and  to  place  his  feet  in  a  hot  mustard 
foot-bath.  Between  two  and  three  o'clock  next  morning  the  patient  was  awakened 
with  an  acute  attack  of  gout  in  both  feet,  when  the  cardiac  irregularity,  dyspnoea, 
and  vertigo  all  disappeared.  Within  the  following  ten  years  this  gentleman  had 
several  similar  attacks,  and  they  were  always  ended  by  an  attack  of  gout  brought  on 
by  immersion  of  the  feet  in  water  as  hot  as  could  be  borne. 

A.  B.,  ast.  fifty-seven,  medical  practitioner,  a  tall,  well-built  man  with  a  large 
head,  burst  into  tears  on  entering  the  consulting-room.  Recovering,  he  said,  "  I  have 
come  here  merely  to  satisfy  my  friends  ;  you  can  do  nothing  for  me  ;  I  have  a  tumour 
under  the  dura  mater  over  the  left  eye."  In  reply  to  the  question  how  he  knew  that, 
he  said  that  several  "  specialists  "  had  given  that  opinion.  He  was  fully  examined,  and 
no  conclusive  evidence  of  the  existence  of  a  tumour  was  discovered.  There  was,  further- 
more, no  sign  of  organic  disease  anywhere  else.  Inquiring  as  to  probable  cause  of  his 
symptoms,  which  were  persistent  headache,  transitory  disturbance  of  vision,  and 
recurring  numbness  and  formication  on  left  side  of  the  body,  it  was  elicited  that  he 
took  a  leading  part  in  the  affairs  of  his  neighbourhood,  that  he  lived  generously,  that 
he  did  not  fret  himself  with  denials  about  the  quantity  of  wine  consumed,  and  that 
he  took  no  exercise  whatever.  Beyond  a  few  scattered  patches  of  eczema,  tinglings 
in  the  feet,  and  indications  of  imperfect  excretion,  no  other  signs  of  grave  disorder 
were  detected. 

To  a  suggestion  of  gout  he  replied  with  indignation,  said  that  it  had  never  existed  in 
his  family,  and  that  he  had  never  done  anything  to  beget  it  in  himself.  When  the 
patient  asked  what  should  be  done  on  the  supposition  that  he  was  gouty,  and  was 
told  that  he  should  live  a  careful  life,  eat  meat  only  once  a  day,  take  regular  exercise, 
ana  substitute  a  little  spirit  and  water  for  wine,  he  replied  that  he  did  not  believe  he 
was  gouty,  and  that  if  he  was,  such  a  regimen  would  destroy  him.  Nothing  more  was 
heard  of  the  patient  for  six  months,  when  Sir  Andrew  Clark  was  summoned  to  the 

country  to  see  a  patient  at  X .     On  arriving  at  the  station,  he  was  met  by  his 

quondam  patient  with  the  cerebral  tumour.    "  Ah ! "  said  Sir  Andrew,  "  why  have  you 


GASTROENTERIC   GOUT.  289 

not  fulfilled  your  promise  to  die  of  your  brain-disease?"  "  Hush,"  said  the  patient, 
"  not  a  word.  You  must  not  mention  the  matter  here  ;  I  have  had  a  famous  attack 
of  gout  in  the  feet,  and  it  has  dissolved  the  tumour  !  " 

The  prevailing  condition  of  the  blood  under  these  conditions  is 
almost  certainly  that  of  diminished  alkalinity  due  to  urichaemia. 
Antecedents  of  cerebral  troubles  are  commonly  on  the  side  of  the 
digestive  system,  whence  a  diminished  formation  of  uric  acid  and 
urea  (according  to  Dr.  Haig),  owing  to  defective  absorption  and 
nutritive  changes,  and  a  lessened  acidity  of  the  blood.  The  latter 
state  entails  the  outcome  of  the  uric  acid  pent  up  in  the  liver 
and  spleen,  which  induces  urichaemia,  and  so  provokes  some  gouty 
manifestation.  Dr.  Haig  has  shown  that  the  amount  of  urea 
falls  from  561  to  363  grains  in  the  four  days  preceding  an  uric 
acid  headache,  owing  to  defective  absorption  and  metabolism. 


Retrocedence  to  the  Stomach  and  Intestinal  Canal. 

Gastro-Enterie  Gout. — The  symptoms  induced  by  gout  alighting 
in  the  stomach  and  intestines  are  multiform.  In  the  simplest 
and  most  unequivocal  cases,  sudden  pain  in  the  stomach  is  the 
first  and  prominent  feature.  With  this  is  associated  great  de- 
pression, bodily  and  mental.  Onset  of  articular  gout  affords 
sudden  and  complete  relief.  Vomiting  sometimes  occurs,  also 
pyrosis  and  retching.  Attacks  of  gastralgia  with  vomiting  may 
occur  from  time  to  time  in  those  subject  to  occasional  fits  of 
frank  gout.  Both  sexes  may  suffer,  perhaps  males  more  fre- 
quently. Gouty  concomitants  are  usually  detectible  in  such 
cases,  forming  manifestations  of  irregular  attacks.  The  gastric 
attacks  do  not  always  terminate  by  articular  outbursts,  but  in  a 
series  of  such  ailments  an  attack  of  frank  gout  may  occur, 
giving  the  clue  to  their  true  nature.  Professor  Ball  and  Dr. 
Buzzard  have  surmised  that  in  some  of  the  cases  in  which  gouty 
affection  of  the  stomach  has  been  diagnosticated,  the  symptoms 
are  properly  referable  to  the  gastric  crises  which  form  part  of 
the  malady  known  as  tabes  dorsalis  or  locomotor  ataxia.  It  is 
well  to  be  mindful  of  the  possibility  of  such  an  error.  Some 
writers  are  sceptical  as  to  the  occurrence  of  gout  in  the  stomach. 
Sir  Thomas  Watson  remarked  that  "gout  (so-called)  in  the 
stomach  was,  under  the  test  of  an  emetic,  sometimes  nothing  more 
than  pork  in  the  stomach."  Without  doubt,  erroneous  diagnosis 
has  often  been  made  of  this  condition  when  other  explanations 
would  have  been  more  in  accordance  with  the  facts  presented. 
But   that   gout  may   seize   upon   the   mucous   membrane   of  the 

T 


290  CLINICAL   VARIETIES    OF    GOUT. 

stomach  and  intestines,  causing  acute  gastro-enteritis,  and  prove 
fatal,  admits  of  no  doubt,  since  autopsies  have  attested  the  fact.1 

Severe  chronic  dyspepsia  may  form  part  of  a  gouty  habit  where 
for  a  long  time  no  joint-symptoms  appear,  or  where  these  are 
very  trifling,  although  highly  significant. 

Application  of  cold  to  gouty  joints  has  often  been  followed  by 
gastric  spasm  ;  even  getting  the  feet  wet  while  they  were  gouty 
has  been  effective  in  inducing  this  condition.  Two  forms  of  gastric 
trouble  are  met  with  as  a  result  of  metastasis :  (a.)  the  spasmodic, 
and  (b.)  the  inflammatory. 

In  Moxon's  remarkable  case,  already  referred  to  (p.  89),  the  latter  form  occurred. 
The  patient  was  a  man,  aet.  thirty-nine,  who  had  suffered  much  from  "  rheumatic 
gouty  "  symptoms,  and  later  became  the  subject  of  albuminuria  and  diarrhoea,  which 
proved  fatal.  The  post-mortem  changes  were  so  noteworthy  that  I  give  them  here 
somewhat  fully. 

In  the  lungs  was  found  early-spreading  phthisis,  with  a  few  clusters  of  recent 
tubercles.  The  heart  was  hypertrophied,  weighing  15^  ounces.  The  stomach  was 
thick-walled  and  rigid  from  inflammatory  infiltration  ;  the  mucous  surface  patched 
unevenly  with  a  layer  of  buff-coloured  fibrin,  which,  on  removal,  brought  away  part 
of  the  mucous  membrane.  The  colon  showed  boil-like  phlegmons  in  the  submucous 
tissue  in  various  stages,  some  ready  to  burst,  some  already  small  abscesses,  others  as 
ulcers,  some  of  the  latter  healing  and  others  cicatrized.  The  kidneys  were  small  and 
granular,  with  sodium  urate  in  grains  in  the  pyramids.  The  cartilages  of  the  great 
toe  and  knee-joints  were  encrusted,  and  rendered  uniformly  opaque  white  by  urates. 
There  was  no  history  of  sudden  retrocedence  of  gout  to  the  stomach  in  this  case. 
As  remarked  by  Moxon,  it  may  be  questioned  if  the  gastritis  and  phlegmonous  colitis 
were  due  in  this  case  to  gout.  Such  changes  are  uncommon  under  any  circumstances, 
and  form  no  part,  at  all  events,  of  concomitant  lesions,  as  ordinarily  met  with,  in 
chronic  interstitial  nephritis.  Tuberculosis  will  not  induce  such  conditions.  Gout 
sometimes  may  do  so.2  A  noteworthy  case  of  retrocedence  to  the  stomach  and  intes- 
tines is  recorded  by  Landre"-Beauvais,  with  an  account  of  the  appearances  after  death. 
I  have  referred  to  this  case  in  the  section  relating  to  gout  in  paralysed  limbs,  p.  234. 

Dr.  Sutton  informs  me  that  he  has  met  with  two  or  three  cases 
in  which  he  made  a  diagnosis  of  gout  in  the  stomach.  They 
occurred  in  men  who  suffered  from  atonic  gout ;  the  symptoms 
were  severe,  and  accompanied  by  great  depression  and  signs  of 
collapse.  The  patients  complained  most  of  distressing  pain  in 
the  epigastric  region  ;  this  was  associated  with  very  anxious  expres- 
sion of  countenance,  cold  sweats,  small  pulse,  and  extreme  restless- 
ness. The  symptoms  yielded  on  supervention  of  gout  elsewhere. 
In  one  case  he  made  an  autopsy  where  the  symptoms  of  rapid 
collapse  led  to  the  belief  that  there  was  cardiac  rupture,  death 
being  sudden.      He  found  no   such    rupture   nor   other   organic 

1  Professor  Ball  of  Paris  thus  expresses  his  view  of  the  relationship  of  a  gouty 
habit  to  disorders  of  the  stomach  : — "  La  goutte  est  pour  l'estomac  ce  que  le  rhutna- 
tisme  est  au  coeur." 
-   2  Vide  Musgrave,  De  Abscessu  Intestinorum  Arthritico,  op.  cit.,  p.  173. 


GASTRECTASIA.  29 1 

changes  to  account  for  the  rapid  death,  save  early  granular  con- 
traction of  the  kidneys  and  much  sodium  urate  deposit  in  and 
around  the  great  toe-joints. 

The  following  case  was  kindly  related  to  me  by  Sir  Andrew  Clark.  J.  J.,  set. 
fifty,  came  home  from  the  Colonies  with  supposed  disease  of  the  stomach.  At  first  his 
chief  symptom  was  merely  pain  after  food,  but  latterly  the  pain  had  become  constant, 
and  was  aggravated  by  everything  ingested.  He  had  lost  flesh,  strength,  and  colour. 
The  circulation  was  hurried,  and  he  was  nervous  and  sleepless.  No  regimen  and 
no  medicine  gave  permanent  relief  ;  but  whilst  using  liquid  food  very  freely,  and 
taking  nightly  a  hot  pediluvium,  he  was  suddenly  seized  with  acute  gout  in  a  hand 
and  foot,  and  from  that  time  all  gastric  symptoms  disappeared. 

This  was  an  example  of  larval  gastric  gout. 

Gastrectasia. — Sometimes,  extreme  dilatation  of  the  stomach 
occurs  in  cases  of  this  nature. 

Gouty  processes  implicating  the  intestinal  tract  express  them- 
selves by  pain,  spasmodic  colic,  vomiting,  and  diarrhoea.  Spas- 
modic and  inflammatory  forms  are  met  with.  Constipation  is 
sometimes  a  consequence.  Such  enterodynia  was  long  since 
recognized  and  termed  "  arthritic  colic."  1  There  may  be  much 
intestinal  flatulent  distension.  Diarrhoea  may  be  the  solitary 
expression  of  gouty  enteritis,  lasting  for  a  few  days,  with  much 
mucous  discharge.  These  attacks  are  apt  to  recur  at  intervals 
of  a  few  weeks,  and  may  alternate  with  regular  fits  in  the 
joints.  Indiscretions  in  diet,  strong  emotions,  or  exposure  to  cold 
may  determine  them.  Warnings  may  appear  in  the  form  of 
slight  pains,  hemicrania,  or  lateritious  sediment  in  the  urine. 
James  Begbie  has  recorded  a  marked  example  which  occurred 
in  his  practice.2  A  clergyman,  eet.  sixty,  of  abstemious  habits,  a 
great  sufferer  from  gout,  which  was  strongly  inherited,  after  a 
longer  interval  of  freedom  than  usual,  was  suddenly  seized  with 
abdominal  pain,  vomiting,  feverishness,  and  great  pain  over  the 
belly,  increased  by  pressure.  There  was  a  small,  rapid  pulse.  The 
first  diagnosis  was  peritonitis.  The  symptoms  did  not  respond 
to  ordinary  treatment.  Surmising  that  gout  might  be  the  cause 
of  the  attack,  colchicum,  which  had  always  relieved  the  articular 
fits  in  a  marked  manner,  was  given.  Copious  diuresis  followed, 
constipation,  which  was  severe,  yielded,  and  speedy  relief  was 
obtained  to  all  the  symptoms. 

These  attacks  may  be  sometimes  unattended  by  pyrexia. 

1  It  is  important  to  note,  in  connection  with  arthritic  colic  as  described  by  Mus- 
grave,  who  long  practised  in  Exeter,  and,  perhaps,  by  other  observers,  that  much  of 
the  gout  seen  by  them  was  due  to,  or  associated  with,  lead-impregnation.  Much  of 
the  colic  described  may  have  been  lead-colic  from  cider-drinking.  It  was  Sir  George 
Baker,  another  Devonshire  man,  who  discovered  the  true  cause  of  the  colic  named 
after  his  county.  2  Op.  cit.,  p.  17. 


292  CLINICAL   VARIETIES    OF   GOUT. 

The  following  case  affords  a  well-marked  example.  A  clergyman,  set.  thirty-four, 
of  robust  figure,  large  head,  hair  dark,  thinning  on  vertex,  inheriting  gout  from  his 
maternal  grandfather,  his  father  also  having  suffered  from  "gravel,"  consulted  me  on 
November  19,  1887.  He  complained  of  periodical  attacks  of  pain,  which  came  on 
gradually  in  the  belly  between  the  navel  and  pubes,  becoming  more  and  more  intense, 
and  lasting  for  about  eighteen  hours,  complete  recovery  not  taking  place  for  three  or 
four  days.  The  pain  radiated  over  the  abdomen,  especially  to  the  left  side.  His  last 
attack,  a  typical  one,  began  at  4  P.M.  on  the  12th  inst.  with  sharp  twinges.  At  3  a.m. 
on  the  following  day  vomiting  occurred,  pulpy  undigested  food  being  rejected.  After 
attacks  of  this,  the  pain  yielded  somewhat,  and  some  heavy  sleep  followed.  By  9  A.M. 
the  intense  pain  had  ceased.  The  urine  was  thick  for  two  days,  and  not  till  the 
1 6th  was  he  entirely  free  from  discomfort. 

These  attacks  began  at  the  age  of  seventeen,  and  recurred  at  first  at  intervals  of 
six  months,  becoming  more  frequent.  For  a  week  before  each  he  felt  "  bilious"  and 
mentally  depressed,  and  his  sleep  was  unrefreshing  and  attended  with  dreams.  At 
these  periods  he  became  giddy  while  reading.  He  had  always  been  a  bilious  subject. 
He  had  suffered  from  several  attacks  of  gout  in  the  heels,  coming  on  suddenly  in 
the  night  after  the  spasmodic  seizures.  The  latter  now  recurred  at  intervals  of  five 
weeks.  He  took  beer  freely  when  at  college.  Certain  "  gout  pills  "  had  been  very 
beneficial.  He  was  a  large  eater,  and  took  meat  three  times  a  day,  sometimes  drink- 
ing beer  at  breakfast. 

There  were  no  signs  of  organic  disease  anywhere  detectible. 

The  urine  (post  jentaculum)  was  alkaline  ;  sp.  gr.  1.020,  void  of  albumen  and  glucose. 
The  tongue  was  fairly  clean. 

He  was  rigidly  dieted  and  ordered  more  exercise.  Blue  pill  and  colocynth  with 
henbane  pill  were  given,  and  an  alkaline  draught  twice  daily  after  food. 

A  month  later  there  was  improvement.  In  his  last  attack  there  was  no  vomiting, 
but  the  pain  was  very  severe  and  lasted  longer  than  formerly,  being  concentrated  in 
the  left  iliac  region.  He  was  now  ordered  to  take  each  night  a  drachm  of  compound 
rhubarb-powder  with  some  dried  sodium  carbonate.  I  saw  no  more  of  this  patient, 
but  a  year  later  he  wrote  that  he  was  "  still  a  cripple  in  the  stomach,  but  got  through 
last  winter  wonderfully  well.  The  pills  were  necessary  as  well  as  the  powder  to 
secure  relief  from  the  bowels.  A  bad  attack  occurred  on  February  28  ;  since  then 
several  approaches  to  one.  The  attacks  have  been  prevented  from  their  final  issue  by 
the  pills.     Smoking  after  meals  causes  pain  in  the  affected  region." 

This  patient  has  probably  been  imprudent  in  diet,  and  not 
benefited  accordingly. 

I  will  add  a  second  example  which  is  characteristic  of  gouty 
gastro-enteritis  with  colic. 

X.  Y.,  set.  thirty-eight,  a  wealthy  merchant,  residing  in  Glasgow,  consulted  me,  in 
November  1888,  for  periodical  attacks  of  abdominal  pain.  He  was  a  tall,  spare  man, 
with  red  hair,  thinning  on  vertex,  and  fairly  robust.  His  parents  were  living,  the 
father  having  suffered  from  "  rheumatic "  pains  in  the  knees,  the  mother  being 
crippled  by  "  chronic  rheumatism,"  which  had  lasted  seventeen  years,  and  suffering 
from  bronchitis.  He  had  only  one  brother,  who  was  subject  to  bilious  attacks, 
followed  by  vomiting.  Ten  years  previously  this  patient  had  suffered  from  "erysi- 
pelas," and  again  last  year  after  an  injury.  The  disorder  was  termed  "  rheumatic 
erysipelas,"  and  spread  all  over  the  body.  In  1863  he  had  pemphigus,  and  three 
years  ago  a  bad  attack  of  eczema.  For  four  years  past  he  had  suffered  once  or  twice 
in  the  month  from  attacks  of  griping  pain  in  the  abdomen,  especially  violent  at  the 
epigastrium,  which  came  on  usually  about  7  p.m.  He  was  unable  to  connect  them 
with  any  habit  of  life  or  any  article  of  diet.     They  would  follow  a  day  of  work  or  of 


COLIC.       VESICAL    GOUT.  293 

pleasure.  The  pain  began  about  his  dinner-time,  and  waxed  steadily  worse  for  twelve 
hours,  preventing  sleep,  and  inducing  retching  and  vomiting  of  frothy  and  watery 
matters,  not  acid  and  not  bilious.  No  jaundice  followed  the  attacks,  but  the  belly 
remained  tender  for  several  days  afterwards.  Slight  chilliness  was  felt  at  beginning 
of  the  paroxysm.  The  pain  tended  to  pass  into  the  right  iliac  region  in  the  course  of 
three  or  four  hours,  when  a  distinct  swelling  could  always  be  felt,  which  his  atten- 
dants had  described  as  due  to  a  "swollen  valve."  This  disappeared  within  the  next 
twenty-four  hours,  and  left  the  parts  in  a  natural  state. 

The  bowels  were  fairly  regular.  Before  the  attacks  there  was  either  constipation, 
or  one  or  two  loose  motions  were  passed  on  the  day  they  occurred.  The  effect  of 
each  seizure  was  to  cause  weakness  and  prostration,  and  to  confine  the  bowels  for  a 
day  or  for  thirty-six  hours,  the  subsequent  motion  being  dark  and  in  detached  lumps. 
The  urine  was  scanty  and  high-coloured  during  the  attacks,  becoming  turbid  on 
standing.     No  feverishness  was  experienced. 

There  was  no  history  of  frank  gout,  but  the  effect  of  a  few  glasses  of  champagne  or 
port  wine  was  to  cause  pains  in  the  knees  and  the  soles  of  the  feet.  He  was  gene- 
rally temperate,  ate  a  good  breakfast,  a  light  luncheon,  and  a  hearty  dinner  with 
sherry  and  claret.     His  habits  were  active,  as  he  walked  and  rode  several  miles  daily. 

He  had  been  to  Bath  on  two  occasions,  and  had  derived  benefit  from  the  waters 
there,  together  with  a  restricted  dietary. 

I  could  detect  nothing  wrong  in  any  of  the  organs.  The  tongue  was  clean,  and 
slightly  indented.     The  urine  was  natural. 

During  the  attacks  nothing  was  found  to  afford  relief,  and  the  stomach  became 
so  irritable  that  no  food  or  medicine  was  tolerated.  The  belly  was  somewhat  dis- 
tended. 

I  prescribed  calomel  in  pills  in  occasional  courses,  with  Friedrichshall  water  and  a 
nightly  dose  of  compound  rhubarb  powder,  and  gave  directions  for  a  very  rigid  diet. 

In  this  case  there  were  plain  indications  of  the  gouty  habit.  It  was  clear  that 
these  attacks  of  gastro-enteritis  with  spasm  were  not  due  to  indiscretions  of  diet  at 
any  particular  time.  Their  recurrence  I  believe  to  have  been  due  to  a  "growing  up  " 
of  a  gouty  state,  induced  by  continual  use  of  unsuitable  diet.  It  is  probable  that 
gout  may  sooner  or  later  supervene  in  more  frank  form  in  some  joint. 

Dr.  George  Budd  described  the  two  varieties  of  gastric  gout 
which  are  to  be  met  with.1  (1.)  The  form  met  with  in  chronic 
gout,  when  there  is  a  feeling  of  weakness  and  sicking,  with 
griping  pain  and  cramp.  Vomiting  is  rare,  and  there  is  no 
pyrexia  or  sign  of  inflammatory  action.  Pressure  relieves  the 
pain.  (2.)  The  form  resulting  from  retrocedence  of  active  gout 
from  a  joint.  Here  there  is  much  pain  in  the  stomach,  pyrexia, 
frequent  retching  or  vomiting,  and  often  profuse  diarrhoea.  The 
symptoms  are  alarming,  and  the  disorder  often  fatal  from  collapse 
within  two  days.  The  treatment  of  the  two  forms  is  very 
different. 

Vesical  Gout— Retroeedenee  to  the  Bladder. — Many  well-marked 
examples  of  gouty  cystitis  have  been  recorded,  in  which  this 
trouble  has  ensued  on  metastasis  from  arthritis.  Exposure  to  wet, 
cold,  and  fatigue  are  common  determinants  in  this  as  in  other 
examples  of  retrocedency.      Urethritis  is  sometimes  thus  induced 

1  On  the  Stomach,  p.  103. 


294  CLINICAL   VARIETIES    OF    GOUT. 

with  puriform  discharge  and  scalding  on  micturition,  and  gonor- 
rhoea is  often  suspected  in  such  cases. 

The  attack  may  come  on  suddenly,  with  pain,  frequent  micturi^ 
tion,  hematuria,  ardor  urinse,  and  restlessness.  The  urine  is 
scanty,  high-coloured,  and  contains  mucus,  blood,  or  pus.  The 
articular  symptoms  are  in  abeyance,  and  the  cystitis  may  persist 
acutely  for  some  days,  and  not  yield  completely  for  many  weeks. 

In  this  case,  as  in  other  instances  of  metastasis,  there  may  be 
symptoms  indicating  that  the  disorder  has  also  alighted  on  other 
parts.  Thus,  the  heart  may  be  affected  after  the  bladder,  and  not 
be  restored  to  its  natural  condition  till  articular  inflammation  is 
again  established.  Gouty  cystitis  is  analogous  to  the  lumbago, 
pneumonia,  bronchitis,  or  gastro-enteritis,  which  sometimes  sud- 
denly vex  subjects  of  retrocedent  gout. 

Elderly  people  are  most  frequently  sufferers  from  this  form  of 
cystitis,  and  prostatic  enlargement  is  often  associated  with  it. 
Bronchitis,  after  being  extremely  rebellious  to  ordinary  treatment, 
may  quickly  yield  to  an  attack  of  gout  in  the  foot. 

Gout  of  the  hollow  viscera  excites  the  same  symptoms,  great 
irritability  of  mucous  surfaces  and  intolerance  of  all  matters 
brought  in  contact  with  them ;  hence,  vomiting,  diarrhoea,  cough, 
and  frequent  micturition,  according  to  the  organs  involved. 

Eczema  has  been  known  to  disappear  from  the  integument, 
and  severe  cystitis  to  set  in  forthwith  in  gouty  subjects.  This 
may  be  regarded  as  an  eczema  of  the  bladder  or  a  visceral 
enanthem. 

Gouty  Orchitis,  Parotitis,  and  Tonsillar  Angina. — Sudden  metas- 
tasis to  the  testis  is  well-recognized,  also  to  the  parotid  gland. 
I  have  already  mentioned  the  transference  of  gouty  (tonsillar) 
angina  to  the  great  toe-joint. 

Urticaria  and  Fugitive  Cutaneous  Congestions. — Gastric  distur- 
bances in  the  gouty  are  sometimes  quickly  relieved  by  the 
occurrence  of  urticaria,  or  of  other  fugitive  congestions  of  the 
integument. 

Acute  articular  gout  may  sometimes  pass  off  without  any 
metastasis  under  the  influence  of  strong  mental  emotion,  such  as 
shock  or  fright,  or  from  the  profound  effect  of  sudden  and  over- 
whelming joy. 


CHAPTER  XIII. 

VISCERAL   GOUT  AND   GOUT   OP   SPECIAL   ORGANS 
AND   TEXTURES. 

Visceral  Gout. 

It  has,  I  believe,  been  sufficiently  shown  in  the  preceding  sections 
that  gout  attacks  the  viscera  as  certainly  as  it  involves  the  joints. 
Hence,  no  apology  is  needed  for  the  term  visceral  gout.  I  have 
described  the  several  affections  which  are  thus  induced,  and  need 
not  refer  to  them  further.  The  chapter  on  the  morbid  anatomy 
of  gout  affords  ample  proof  of  their  existence.  We  have  seen 
that  both  functional  and  organic  disease  of  the  viscera  and  of 
abarticular  parts  may  be  due  to  gouty  dyscrasia. 

The  causation  of  visceral  attacks  is  probably  exactly  that  of 
articular  paroxysms.  Retention  or  precipitation  of  uratic  salts 
in  any  locality  is  apt  to  induce  a  gouty  fit,  and  hence  hypersemia, 
irritation,  pain,  and  inflammatory  symptoms  of  varying  degree  in 
such  parts,  with  special  indications  of  perverted  function,  according 
to  the  organ  involved. 

Illustrative  examples  are  furnished  by  bronchitis,  cystitis, 
orchitis,  parotitis,  neuritis,  phlebitis,  gastro  -  enteritis,  and  the 
condition  of  the  liver  in  respect  of  glycosuria  in  the  acute  form, 
or  in  exacerbations,  as  met  with  in  persons  while  suffering  from  a 
more  than  usually  gouty  state  of  the  system.  Personal  proclivity 
and  tissue-state  probably  have  to  do  with  the  peculiar  determina- 
tion, while  the  dominating  condition  of  the  nervous  system  acts 
no  less  forcibly  in  each  case. 

Retrocedency  of  gouty  process  to  any  organ  affords  an  apt 
illustration  of  visceral  gout  admitting  of  no  dubiety. 

It  has  already  been  shown  that,  in  cases  of  gouty  heredity, 
various  organs  may,  even  in  early  life,  be  the  seat  of  disturbances 
due  to  that  dyscrasia,  and,  further,  that  such  manifestations  may 


296  VISCEEAL    GOUT,    ETC. 

be  substitutions  for  more  obvious  articular  symptoms,  which,  how- 
ever, may  supervene  later  in  life.  To  use  the  words  of  Charcot, 
"  When  the  visceral  affection  precedes  the  articular  gout,  and  con- 
stitutes for  a  longer  or  shorter  time  the  only  manifestation  of  the 
diathesis,  it  is  called  larval  gout ;  when,  on  the  contrary,  it  follows 
the  articular  symptoms,  it  is  called  retrocedent,  provided,  at  least, 
that  the  metastasis  has  been  excited  by  the  intervention  of  an 
external  cause^ — cold,  for  example." * 

The  viscera  may  be  primarily  attacked,  or  become  secondarily 
involved  by  retrocedence  of  gouty  process  from  joints  or  other 
parts.  It  would  be  strange  if,  in  a  disorder  of  the  whole  body, 
any  part  were  spared,  and  it  has  been  shown  that,  with  the 
possible  exception  of  the  lymphatic  glands,  none  of  the  bodily 
textures  are  exempt  from  overt  manifestations  of  the  disease. 

The  liver,  as  the  largest  viscus,  is  perhaps  more  concerned  than 
any  other  organ.  The  kidneys  suffer  as  severely  as  any  joint  from 
textural  changes.  The  heart  and  vascular  system  generally,  and 
the  lungs  bear  the  full  stress  of  perverted  nutrition  in  consequence. 
The  skin,  the  alimentary  tract  in  all  its  length,  the  bladder,  testes, 
penis,  parotid  glands,  and,  without  doubt,  the  brain  and  nerves, 
may  all  be  involved. 

By  inheritance,  as  has  been  shown,  the  gouty  habit  impresses 
its  peculiar  features  on  the  as  yet  uninfluenced  tissues  of  the  body, 
implanting  a  veritable  gouty  physiognomy,  capable  of  recognition 
in  early  adult  life. 

Certain  gouty  persons  are  more  apt  to  present  visceral  than 
articular  phases  of  the  dyscrasia,  others  the  reverse  of  this. 

Many  disorders  of  the  viscera  may  be  recognized  as  of  gouty 
nature,  when  as  yet  no  plain  signs  of  articular  gout  have  super- 
vened. A  sudden  and  fugitive  type  commonly  attaches  to  these. 
Thus,  in  some  individuals  a  periodical  recurrence  of  bronchial 
catarrh,  of  functional  disorder  of  the  liver,  of  headaches,  and 
various  other  troubles,  is  sometimes  a  truly  gouty  expression,  and 
demands  treatment  in  accordance  with  this  view  of  their  intimate 
causation.  Certain  fluxes,  bloody  or  otherwise,  are  of  this  nature, 
as  severe  epistaxis  in  the  daughters  of  gouty  fathers,  which  may 
recur  occasionally  through  a  long  life,  and  prove  of  no  moment, 
possibly  being  rather  salutary,  and  calling  for  no  such  inter- 
ference as  plugging  of  the  nostrils.  The  blood  is  soon  made 
up,  and  its  loss  may  avert  worse  consequences.  A  diagnosis  of 
the  true  significance  of  cases  of  this  nature  is  hardly  possible 
without  careful  inquiry  into  family  history  and  proclivity,  and 
1  Lecons  sur  les  Maladies  des  Vieillards  et  les  Maladies  Chroniques,  Paris,  1868. 


GOUT   AS    AFFECTING   THE    HEART.  297 

in  ignorance  of  this,  errors  both  in  treatment  and  prognosis  may 
readily  be  fallen  into. 

Haemorrhage  from  the  bladder  in  elderly  men  of  gouty  habit 
is  another  case  in  point.  No  treatment  is  called  for,  and  no 
harm  results. 

Several  grave  diseases  of  the  eye  are  illustrative  in  this  rela- 
tion. The  gouty  habit,  or  taint,  is  sufficient  to  induce  these.  It 
is  an  error  to  expect  always  a  history  of  articular  gout  in  such 
cases.  It  may,  or  may  not,  be  forthcoming.  The  life-  and  family 
history  of  the  patient  commonly  afford  the  clue  to  aetiology  in 
these  cases.  Herein,  as  I  am  well  aware,  lies  the  great  danger 
of  pronouucing  too  readily  for  gouty  influence.  This  snare  will 
not  entrap  those  who  are  duly  cautious,  and  only  anxious  to  seek 
the  truth,  and,  in  any  doubtful  case,  an  open  mind  must  be  kept. 
A  large  and  varied  field  of  work  is  the  best  school  wherein 
to  chasten  hasty  and  crude  opinions  in  any  class  of  ailments. 
Specialism  is  notoriously  warping  to  the  mind,  and  inducive  of 
error. 

Visceral  gout  is  commonly  a  phase  in  the  chronic  form  of  the 
disorder,  and  in  its  acutest  forms  is  seen  in  the  several  metastases, 
which  are  duly  recognized.  The  storms  (as  they  have  been 
termed)  of  glycosuria  met  with  in  the  gouty  have  been  sugges- 
tively considered  by  Dr.  Ord  as  due  to  hepatic  gout,  the  hyper- 
aemia  and  undue  activity  of  the  liver  being  sometimes  a  substi- 
tution for  articular  troubles.  In  the  chronic  interstitial  nephritis 
of  gout  there  are  sometimes  active  phases  of  disturbance  in  the 
kidney,  leading  to  more  than  the  wonted  polyuria  or  to  increased 
albuminuria.  A  fugitive  and  a  sudden  character  pertains  to  these 
phases,  very  suggestive  of  the  like  manifestations  in  gouty  joints. 
So,  with  respect  to  bronchitis,  gastric  catarrh,  neuralgia,  hemi- 
crania,  and  many  other  ailments  attaching  to  the  dyscrasia.  The 
local  afflux  subsides,  and  the  parts  return  to  their  normal  trophic 
equilibrium,  at  whatever  level  that  may  be. 

In  this  chapter  I  propose  to  describe  more  in  detail  some  of  the 
characters  of  gout  as  affecting  certain  organs  and  other  abarti- 
cular  parts. 

Gout  as  Affecting  the  Heart. — The  morbid  anatomy  of  the  heart, 
as  met  with  in  fatal  cases  of  gout,  has  been  already  described. 
The  gross  changes  discovered  form  part  of  the  wide-spread  dege- 
nerations associated  with,  if  not  actually  dependent  on,  chronic 
gout.  Thus,  they  are  commonly  related  to  the  degree  of  sclerosing 
nephritis  present  in  such  cases,  and  are  also  more  or  less  depen- 
dent on  the  condition  of  the  coronary  arteries  in  respect  of  indu- 


298  VISCERAL    GOUT,    ETC. 

ration  and  atheroma.  Chronic  valvulitis  may  be  induced,  with 
consecutive  hypertrophy.  Dilatation  may  follow  on  this  as  a 
result  of  general  failure  of  nutrition,  aggravated,  commonly,  by 
imperfect  blood-supply  through  the  coronary  arteries. 

The  occurrence  of  painful  cardiac  neuroses,  such  as  true  and 
pseudo-angina  pectoris,  has  been  previously  discussed.  In  chronic 
gout,  cardiac  action  may  be  preternaturally  violent  and  rapid,  or, 
again,  remarkably  infrequent.  Intermittency  of  the  pulse  has 
long  been  recognized  in  certain  cases  as  dependent  on  gout,  and 
is  more  often  met  with  in  practice  than  the  reverse  condition  of 
tachycardia.  Either  state  may  excite  much  concern,  and  demands 
careful  analytical  study. 

It  has  been  axiomatically  laid  down  that  an  irregular,  inter- 
mittent pulse  in  persons  past  the  prime  of  life,  and  especially  if 
associated  with  derangement  of  the  functions  of  the  stomach,  and 
unaccompanied  by  any  clear  indication  of  disease  of  the  heart, 
will  frequently  be  found  to  be  due  to  gout. 

Professor  Burdon  Sanderson  has  directed  attention  to  irregu- 
larity of  pulse  in  persons  of  gouty  constitution  where  no  cardiac 
valvular  disease  is  present,  and  shown  that  the  cardiac  rhythm 
may  be  regular  during  an  attack,  and  become  irregular  at  other 
times.1 

"  During  the  period  of  inspiration,  the  frequency  of  the  heart's 
contractions  is  increased,  the  pulse  becomes  dicrotic,  its  form  being 
entirely  different  from  that  which  it  assumes  during  the  respira- 
tory pause,  when  it  is  relatively  retarded.  During  the  respiratory 
pause,  on  the  other  hand,  the  contractions  are  less  frequent,  the 
diastolic  intervals  are  longer,  so  that  the  heart  has  time  to  fill 
completely  before  it  contracts.  Hence,  the  quantity  of  the  blood 
delivered  into  the  aorta  is  much  larger  in  proportion  to  the 
quantity  which  can  be  transmitted  by  the  capillaries.  The  dura- 
tion of  the  ventricular  systole  is  greater,  and  the  arteries  remain 
a  much  longer  time  distended.  The  pulse  is  no  longer  dicrotic. 
Thus,  in  one  and  the  same  individuals  you  have  dicrotism  during 
inspiration,  absence  of  dicrotism  during  the  respiratory  pause ; 
the  only  difference  in  the  state  of  the  circulation  being  that,  in 
the  one  case,  the  diastolic  pause  is  shortened,  and  consequently 
the  ventricle  contracts  upon  an  insufficient  supply  of  blood ; 
whereas,  in  the  other,  its  expansion  is  complete  and  its  systole 
effectual." 

As  pointed  out  by  G.  W.  Balfour,  cases  of  palpitation  in  the 
gouty  are  apt  to  be  subdued  by  emotional  excitement  or  exertion, 
1  On  the  Sphygmograph,  p.  76. 


GOUT   AS    AFFECTING    THE    HEART.  299 

the  reverse  condition  occurring  when  organic  valvular  disease  is 
present.  The  discomfort  of  palpitation  is  relieved  although  the 
cardiac  beats  are  more  frequent.  Another  point  of  distinction 
between  functional  disorder  of  the  heart  arising  from  gout,  and 
symptoms  due  to  organic  disease,  lies  in  the  subjective  character 
of  the  palpitation  in  the  former,  there  being  sometimes  thumping, 
or  tumbling,  sensations  with  little  or  no  dyspnoea,  while  in  the 
latter  dyspnoea  is  both  subjective  and  objective,  and  generally  well- 
marked,  palpitation  not  being  a  constant  or,  when  present,  a  very 
distressing  symptom. 

Gout  alighting  on  the  heart  by  retrocedence  from  other  parts 
has  been  referred  to.  In  such  cases  there  is,  so  far  as  my  know- 
ledge goes,  no  clinical  or  other  proof  of  any  inflammatory  pro- 
cess involving  the  muscular  walls,  or  of  endo-  or  peri-carditis. 
The  latter  is  only  known  as  a  complication  in  associated  chronic 
nephritis. 

In  cases  of  gouty  irregularity  of  the  pulse,  special  regard  must 
be  had  to  the  volume,  which  is  good  so  long  as  the  heart  is  orga- 
nically sound.  If  the  cardiac  walls  are  softened  and  dilated  as 
the  result  of  degeneration,  there  may  be  small  volume  and  low 
tension  associated  with  the  irregularity.  The  intermittent  char- 
acter may  pass  off  after  a  short  time,  or  may  remain  for  many 
years  without  prominent  symptoms. 

Extreme  infrequency  may  be  observed  where  the  heart  is  feeble 
and  dilated,  the  pulsations  falling  as  low  as  twenty  in  the  minute, 
as  recognized  at  the  wrist,  but  occurring  with  greater  frequency 
at  the  heart,  many  of  the  beats  not  being  forcible  enough  to  reach 
the  distal  arteries.1  Sometimes  intermittency  depends  on  purely 
nervous  causes,  apart  from  gout,  in  gouty  subjects ;  but  there  is 
probably  in  some  of  these  cases,  as  part  of  the  gouty  neurosis,  an 
unstable  condition  of  the  cardiac  centres  in  the  medulla  oblongata. 

Here,  as  always,  the  gravity  in  any  particular  instance  is  to 
be  gauged  by  the  nutritional  state  of  the  cardiac  walls,  and  the 
general  condition  of  the  patient  in  respect  of  gouty  cachexia. 

Where  the  gouty  habit  is  plainly  established,  the  prognosis  is, 
so  far,  not  unfavourable  if  the  heart  be  fairly  sound  and  the 
renal  functions  unimpaired.  Intermittency  per  se  is  not  a  grave 
symptom,  but  with  associated  degenerative  changes  the  case  is 
very  different,  and  the  outlook  unfavourable. 

1  A  noteworthy  instance  in  point  is  recorded  by  G.  W.  Balfour,  where  this  was 
observed  in  an  old  lady,  "long  gouty,  though  without  regular  attacks,"  with  feeble 
and  dilated  heart,  who  suffered  from  epileptiform  attacks,  associated  with  flatulent 
dyspepsia.  These  passed  off,  and  life  was  prolonged  for  some  years  without  any 
return  of  the  severe  symptoms.     Diseases  of  the  Heart,  p.  258. 


300  VISCERAL   GOUT,    ETC. 

A  similar  prognosis  attaches  to  the  like  symptom  as  sometimes 
permanently  induced  by  malarial  fevers,  in  which  case  old  age 
may  be  reached. 

The  sudden  deaths  which  occasionally  overtake  the  gouty  are 
probably  always  due  to  aortic  disease  or  to  fatty  heart,  and 
depend  on  syncope,  or  on  rupture  of  the  left  ventricle.  The  fatal 
event  may  be  determined  by  an  attack  of  gout,  which  disturbs 
the  cardiac  action.  Where  this  is  not  present,  the  case  may  be 
erroneously  supposed  to  be  one  of  retrocedency. 

A  pulse  of  high  tension  is  very  commonly  met  with  in  the 
gouty,  but  is  by  no  means  always  to  be  found.  It  may  occur 
long  antecedent  to  cirrhosing  change  in  the  kidneys,  but  is  pro- 
bably often  in  relation  to  that  change,  and  may  be  expected  in 
association  with  it  as  part  of  the  car dio- vascular  degeneration. 
Continued  high  arterial  pressure  tells  in  its  wonted  manner  more 
especially  on  the  aortic  valves,  leading  to  sclerosis,  and  inducing 
thereby  either  stenosis,  or  permanent  patency,  or  both.  The 
mitral  valves  also  partake  of  this  change  in  consequence  of  strain, 
the  same  sclerosing  endocarditis  here  leading  to  reflux,  and  some- 
times to  stenosis.  Without  question,  mitral  valvular  lesions  are 
most  often  due  to  rheumatic  disease,  but  gout  sometimes  plays  a 
part,  albeit  a  small  one,  in  inducing  sclerosing  change  in  the  manner 
just  indicated.  Hence,  elderly  men  may  present  symptoms  of 
this  disease  in  association  with  obvious  gouty  dyscrasia,  in  whom 
no  previous  history  of  rheumatism  is  to  be  met  with.  The 
more  ordinary  rheumatic  form  is  an  appanage  of  early  life,  and 
very  specially  of  the  female  sex.  In  the  gouty  form,  as  seen  in 
elderly  persons,  there  are  not  present,  unless  degeneration  of  the 
cardiac  walls  has  taken  place,  the  well-recognized  symptoms 
associated  with  mitral  stenosis  in  the  young.  The  heart  may 
be  vigorous  and  acting  forcibly,  although  the  pulse  is  irregular 
as  to  rhythm  and  volume.  If  severe  bronchitis  occurs,  the  right 
side  of  the  heart  may  yield  under  stress  of  this,  and  add  to  the 
gravity  of  the  case. 

Where  high  arterial  tension  prevails  in  any  case,  it  is  not  an 
abiding  condition.  It  may  vary  from  day  to  day  and  from  hour 
to  hour.  It  is  met  with  in  acute  and  in  chronic  gouty  states,  also 
in  incomplete  or,  so-called,  suppressed  gout. 

The  contamination  of  the  blood  by  imperfectly  metamorphosed 
products  insufficiently  oxydized  is  the  primary  cause  of  it,  the 
capillary  circulation  throughout  the  body  being  thus  impeded. 
Hence  lithsemia,  pregnancy,  anaemia,  and  lead-impregnation  are 
well-recognized  causes  of  increased  blood-pressure  in  the  arteries. 


RENAL    CALCULI.  3OI 

In  the  latter  case,  as  suggested  by  Broadbent,  there  may  pro- 
bably be  formed  albuminates  of  lead,  which  are  too  stable  for 
dissociation  and  oxydation,  and  it  is  proved  that  lead  checks 
elimination  of  uric  acid  from  the  system.  Lime-salts  in  excess 
probably  act  similarly,  and  both  tend  to  induce  gout. 

Continued  dyspepsia,  common  as  an  antecedent  in  gout,  and 
more  common  as  an  irregular  phase  of  it,  may  in  time  set  up 
arterio-capillary  fibrosis  and  high  pressure  of  the  blood-column 
as  a  result.  Causes  of  high  tension,  acting  temporarily,  may  on 
passing  away  leave  the  pulse  of  natural  firmness.  In  the  gouty 
habit  the  tendency  is  very  apt  to  remain  in  greater  or  lesser 
degree. 

It  may  not  always  be  recognized  by  the  finger,  and  may  only 
be  demonstrated  by  the  sphygmograph  when  skilfully  applied. 
The  specific  connection  of  high  pulse-tension  with  urichsemia  has 
within  the  last  few  months  been  proved  by  Dr.  Haig.1 

In  gouty,  as  in  other  states,  high  blood-pressure  may  be  reduced 
by  appropriate  medicinal  and  dietetic  treatment,  and  efforts  in 
this  direction  are  desirable  in  any  case  where  obviously  untoward 
symptoms  are  present  in  association  with  it,  regard  being  always 
had  to  the  well-being  of  the  patient,  whatever  his  ailment. 

The  sphygmographic  tracings  depicted  on  page  223,  figs.  17— 
20,  illustrate  some  of  the  features  of  the  pulse-wave  in  cases  of 
gouty  habit. 

Renal  Calculi  in  Relation  to  Gout. 

There  is  an  unquestionable  relation  between  the  gouty  habit 
and  the  formation  of  uratic  calculi  in  the  kidney.  It  is  rare  for 
gravel  and  gout  to  co-exist.  Passage  of  gravel  most  often  pre- 
cedes gout,  and  ceases  on  the  supervention  of  it.  The  two 
conditions  may  alternate.  Calculi  may  occur  without  any  overt 
gouty  manifestations,  but  cases  are  met  with  in  which,  after 
distinct  attacks  of  gout,  calculous  renal  symptoms,  such  as  pain 
and  hematuria,  come  on,  and  ordinary  gouty  symptoms  subside. 
This  may  occur  even  in  the  third  decade  of  life,  of  which  an 
instance  has  been  related  to  me  by  my  colleague,  Mr.  Langton. 

In  another  case,  a  man  of  fifty-seven  years  of  age  suffered 
from  several  severe  attacks  of  gout  in  the  great  toes,  and  in 
ten  years  began  to  suffer  from  hematuria,  which  lasted,  with 
short  and  incomplete  remissions,  for  eighteen  months.  There 
was  no  very  marked  lumbar  pain.  There  were  no  signs  of  dis- 
ease of  the  bladder,   and  although  no  calculous   particles  were 

1  Brit.  Med.  Journ.,  February  9,  1889. 


302  VISCERAL   GOUT,    ETC. 

passed,  I  entertained  no  doubt  as  to  the  presence  of  stone  in  the 
kidney.      There  were  no  indications  of  new  growth  in  this  case. 

When  the  calculi  are  large,  they  have  little  or  no  tendency  to 
move,  and,  hence,  symptoms  of  renal  colic  are  not  met  with  in 
such  cases.  The  worst  cases  of  nephralgia  and  colic  due  to  cal- 
culous formation  appear  to  be  connected  with  the  presence  of 
small,  rough,  and  readily  removable  stones — in  the  earlier  stages, 
therefore,  of  the  disorder.  In  some  cases  of  calculous  kidney  pain 
is  absent,  or  but  little  marked,  and  may  be  indifferently  referred 
to  the  lumbar  region,  and  hardly  to  one  side  rather  than  the 
other.1  Mr.  Knowsley  Thornton  has  affirmed  that  the  symptoms 
of  stone  in  one  kidney  may  be  caused  by  the  presence  of  stone  in 
the  opposite  organ ;  but  it  would  not  be  safe  to  reckon  on  this, 
if  operative  procedures  were  contemplated.  The  calculi  usually 
consist  of  uric  acid,  but  may  contain  ammonium  urate  or  calcium 
oxalate.  They  may  be  formed  of  alternate  layers  of  these.  Uric 
acid  calculi  are  perhaps  the  most  brittle  of  all  forms  met  with. 
They  sometimes  break  up  spontaneously  in  the  bladder. 

A  case  is  recorded  by  Dr.  Ord,2  in  a  gouty  man,  aged  eighty- 
four,  of  great  bulk  and  weight,  in  which  spontaneous  disruption 
occurred  in  uric  acid  and  ammonium  urate  calculi.  Many  spheri- 
cal calculi  were  passed,  their  fragments,  like  segments  of  exploded 
shells,  indicating  that  they  had  broken  some  time  before  emission. 
Dr.  Ord  believed  the  fracture  to  be  due  to  an  expansion  of  the  central 
portion,  acting  like  the  exploding  powder  in  a  shell,  caused  by  the 
action  of  alkaline  urine,  which  led  to  swelling  of  mucoid  matter  in 
their  composition.  He  refers  to  several  other  examples  which  sup- 
port his  view  as  to  the  cause  of  disruption.  Dr.  Debout  d'Estr^es, 
of  Contrexeville,  showed  me  some  calculi  of  uric  acid  which  had 
thus  broken  up,  and  he  attributed  the  fracture  to  powerful  de- 
trusive  action  of  the  bladder,  which  crushed  the  stones  against 
each  other.  In  my  opinion,  Dr.  Ord's  explanation  is,  probably, 
the  most  rational  one. 

It  is  well  known  that  hematuria  may  long  and  severely  persist 
in  consequence  of  very  small  renal  calculi.  The  experience  of 
large  numbers  of  cases  successfully  treated  at  Contrexeville  and 
elsewhere  incontestably  proves  this.  The  personal  and  family 
history  in  many  such  cases  justifies  the  opinion  that  the  uric  acid 

1  One  of  the  most  remarkable  instances  of  renal  calculi  on  record  occurred  in  a 
man,  set.  thirty-eight,  who  had  been  gouty  for  eleven  years,  and  had  tophi.  His 
father  was  gouty.  There  were  more  than  a  thousand  stones  in  the  two  kidneys,  and 
one  weighed  36^  and  another  9!  ounces.  (Dr.  Gee's  Case,  St.  Barth.  Hosp.  Museum, 
Series  xxviii.,  No.  2349.)     Vide  Med.  Chir.  Trans.,  vol.  lvii.  p.  77,  1874. 

3  Op.  tit.,  p.  93. 


PROSTATIC    GOUT.  303 

disturbance  constitutes  for  them  a  variety  of  abarticular  gout.  In 
many  others  no  such  opinion  is  warrantable.  It  is  important 
to  make  the  diagnosis  of  renal  calculus  in  many  cases  where  no 
fixed  lumbar  pain  or  history  of  ureteric  spasm  exists.  Recurring 
haemorrhage  is  often  the  sole  symptom.  Where  cachectic  states 
are  present  or  indications  of  granular  kidney  prevail,  haemorrhage 
may  occur,  occasionally  to  a  considerable  amount,  independently 
of  calculous  irritation.  I  have  noted  the  occurrence  of  vesical 
bleedings  in  the  gouty,  and  feel  sure  that  these  may  occur  in  the 
kidney,  as  elsewhere, — so  as,  e.g.,  to  induce  epistaxis  or  hcemate- 
mesis, — because  of  a  bad  state  of  the  blood-vessels,  which,  from 
senile  or  other  forms  of  decay,  become  brittle.  These  may  all,  or 
singly,  be  the  precursors  of  cerebral  haemorrhage.  The  latter  is 
apt  to  occur  in  the  gouty,  with  granular  kidneys,  without  any 
bad  state  of  the  arteries  generally.  I  have  known,  for  example, 
a  strong  man,  aged  forty-nine,  whose  arteries  were  very  good, 
struck  down  with  fulgurant  apoplexy,  due  to  large  haemorrhage. 
There  may  have  been  a  small  aneurysm,  but  it  was  not  detected. 
The  kidneys  were  granular,  with  uratic  streaks  in  the  pyramids, 
and  the  cartilages  of  the  great  toe-joints  were  plastered  with  urates. 
There  was  hypertrophy  of  the  cardiac  left  ventricle.1 

Gouty  Hsematuria. — In  persons  of  gouty  habit,  over  seventy 
years  of  age,  sudden  and  severe  vesical  haemorrhage  may  occur, 
and  clots  form  in  the  bladder.  No  harm  may  result  from  this 
somewhat  alarming  symptom,  which  is  better  left  untreated,  atten- 
tion being  directed  solely  to  the  state  of  the  bladder,  from  which 
the  clots  may  have  to  be  withdrawn  by  suction. 

Prostatic  Gout  is  occasionally  met  with.  It  affects  elderly  men 
who  may  have  previously  had  no  articular  attacks.  Severe  pain 
may  come  on  suddenly  in  the  night,  with  pain  and  spasmodic 
dysuria.  There  may  be  associated  pain  in  the  groin,  perineum, 
and  testes.  The  urine  is  scanty  and  charged  with  urates.  The 
prostate  is  found  enlarged  and  very  sensitive  when  examined  by 
the  rectum.  The  bladder  is  imperfectly  emptied.  The  attack 
may  subside  and  leave  the  prostate  enlarged  for  some  time  sub- 
sequently with  a  condition  of  cystitis.2  Exposure  to  cold  and 
wet  is  often  the  determinant. 

Gouty  Dyspepsia. — It  has  been  pointed  out  that  some  form  of 
catarrhal  dyspepsia  is  commonly  associated  with  gout  in  its 
paroxysmal  form.  It  may  be  acute,  and  be  relieved  by  the  onset 
of  the  attack,  or  it  may  persist  after  this  is  established.      Retro- 

1  Under  the  care  of  Dr.  Church.     Vide  Hoap.  P.M.  Book,  February  16,  1889. 

2  Reginald  Harrison  on  Prostatic  Gout.     Lancet,  November  24,  1883,  p.  896. 


304  VISCERAL   GOUT,    ETC. 

cedence  of  gouty  symptoms  from  a  joint  to  the  stomach  has  also 
been  discussed. 

I  refer  now  to  the  occurrence  of  gastric  catarrh  as  a  somewhat 
frequent  phase  of  a  gouty  habit  of  body.  The  tendency  is  met 
with  at  an  early  age,  and  may  persist  from  time  to  time  through- 
out life  in  persons  who  do  not  develop  any  marked  articular 
disturbance. 

Pain,  acidity,  and  flatulence  are  leading  symptoms.  The 
tongue  is  furred  more  or  less,  and  the  appetite  may  be  im- 
paired, or  unchanged.  In  acute  forms,  cardialgia  and  vomiting 
may  occur,  and  relief  may  follow  the  latter.  Some  dietetic 
indiscretion  may  induce  this.  In  other  cases,  the  catarrhal  state 
appears  as  an  irritative  dyspepsia  from  time  to  time,  and  may, 
or  may  not,  be  dependent  on  habitual  over-eating.  The  liver  is 
probably  in  fault,  and  by  periodic  congestive  states  leads  to  portal 
venous  plethora,  and  catarrh  of  the  mucous  surfaces  drained  by  it. 
Such  patients  speak  of  their  liver  being  "  sluggish,"  meaning  by 
this  that  they  suffer  from  constipation. 

Sometimes,  craving  for  food  is  a  symptom,  and  one  which  must 
not  be  gratified.  Sense  of  sinking  at  the  epigastrium  may  occur. 
Periodical  attacks  of  gastrodynia  with  headache  and  vomiting 
of  mucus  have  been  known  to  yield  to  attacks  of  lumbago  and 
sciatica. 

The  urine  in  cases  of  gouty  dyspepsia  is  commonly  loaded  with 
lithates,  and  many  of  the  symptoms  of  lithsemia  may  be  met  with. 
The  faeces  are  apt  to  be  pale,  knotty,  and  scanty  during  the 
attack. 

Patients  thus  affected  are  readily  made  worse  by  errors  of  diet, 
excess  of  any  kind  of  food  being  harmful,  even  of  simple  articles, 
such  as  farinaceous  matters.  They  are  commonly  sensitive  to 
chill,  and  exposure  to  keen  winds  may  determine  a  gastric  attack 
in  several  ways.  It  may  check  the  action  of  the  skin,  and,  so, 
cause  congestion  of  the  internal  organs  at  the  same  time  that 
the  appetite  for  food  is  heightened.  Portal  venous  plethora  and 
catarrh  are  thus  readily  provoked,  and  a  so-called  "  bilious  attack  " 
is  set  up. 

Gouty  dyspepsia  may,  thus,  be  primarily  of  gastric  or  of  hepatic 
origin,  and  the  catarrhal  variety  is  the  most  common.  I  have 
already  discussed  the  spasmodic  and  the  inflammatory  forms  of 
gastric  and  intestinal  dyspepsia  occasionally  met  with. 


NEURITIS.  305 


Gouty  Neuritis. 

The  occurrence  of  gouty  neuritis  as  a  definite  ailment  has  not 
been  long  recognized.  It  is  a  most  troublesome  and  painful 
disorder.  The  symptoms  have,  no  doubt,  been  commonly  mis- 
interpreted, and  classed  with  vague  gouty  or  rheumatic  pains,  or 
with  neuralgia.  In  all  cases  there  is  a  plain  history  of  gouty 
ailments  or  heredity.  The  subjects  are  usually  in  middle  life, 
and  may,  or  may  not,  have  had  classical  attacks  of  articular  gout. 
The  evidence  of  the  gouty  nature  of  this  disorder  is  clinical  and 
not  pathological. 

Mr.  Hutchinson  has  noted  cases  of  optic  neuritis  which  he 
believed  to  be  of  gouty  origin. 

The  symptoms  are  chiefly  sensory  in  most  cases,  but  motor 
affection  has  been  also  observed.  Thus,  numbness  and  tingling, 
"  pins  and  needles  "  in  an  extremity,  are  the  commonest  symp- 
toms, but  the  pain  may  be  sometimes  agonizing.  Loss  of  power 
in  the  affected  limb  may  also  occur,  and  some  muscular  atrophy 
may  result.  I  think  it  is  not  unlikely  that  some  cases  of 
neuralgia  in  the  gouty  are  due  to  minor  degrees  of  neuritis  or 
perineuritis,  since,  with  more  or  less  constant  pain,  there  are  often 
severe  paroxysms. 

The  most  severe  form  constitutes  a  variety  of  sciatica.  It  is 
probable  that  the  perineurium  is  affected  by  gouty  inflammation, 
which  leads  to  thickening  and  compression  of  the  nerve-bundles. 
This  can  be  plainly  felt  in  some  superficially  placed  nerves. 
Thus,  I  have  met  with  it  in  the  ulnar  nerve  above  the  elbow,  a 
distinct  tumour  being  felt,  exquisitely  painful  on  slight  pressure, 
extending  for  a  fourth  of  an  inch  or  more  along  the  nerve- 
trunk. 

To  determine  the  diagnosis  in  any  case,  there  must  be  un- 
equivocal evidence  of  gouty  habit  or  concomitants,  and  the 
blood  may  be  appealed  to  for  evidence  of  increased  amount  of 
uric  acid  in  it. 

The  occurrence  of  gouty  neuritis  is  determined,  as  it  appears 
to  me,  very  much  as  are  attacks  of  gouty  phlebitis,  and  I  have 
met  with  both  affections  in  the  same  individual  at  different  times. 

The  early  peripheral  tinglings  much  resemble  those  met  with 
in  alcoholic  neuritis,  but  are  usually  less  severe,  and  a  complete 
study  of  peripheral  neuritis  must  include  this  class  of  cases. 

With  the  exception  of  the  great  sciatic  nerve,  the  trouble  is 
more  prone  to  occur  in  branches  of  the  brachial  plexus.      The 

U 


306  VISCERAL    GOUT,    ETC. 

worst  cases  I  have  met  with  have  involved  this  plexus,  or 
some  of  its  roots  at  their  emergence  in  the  lower  cervical  region. 
A  degree  of  neuralgic  character  naturally  pertains  to  neuritis, 
paroxysms  of  pain  being  apt  to  occur  from  time  to  time,  readily 
induced  by  such  movements,  often  very  delicate,  as  disturb  the 
affected  branches  mechanically.  Pressure  is  badly  borne,  and 
will  excite  agonizing  pain.  A  prominent  feature  of  this  trouble 
is  its  persistency  and  rebelliousness  to  treatment.  I  believe 
that  a  localized  patch  of  gouty  inflammation  is  the  starting- 
point,  specially  affecting  the  perineurium,  and  leading  to  effusion 
into  the  nerve-sheaths.  The  adjacent  lymph-spaces  are  probably 
involved,  and  these  are  possible  sites  of  deposition  of  acid  uratic 
salts.  Some  long  period  must  elapse  before  these  deposits  can  be 
removed. 

With  the  nerve-changes  come  altered  electrical  reactions  of  the 
efferent  fibres  and  the  muscles  supplied  by  them.  Dr.  Buzzard  has 
directed  attention  to  these  in  several  cases.1  Thus,  in  a  lady,  aet. 
fifty-two,  the  left  hand  would  close  during  the  night,  and  could 
not  be  opened  without  severe  pain  in  the  wrist  and  fingers.  It 
would  be  found  icy  cold.  Previously,  there  had  been  tinglings 
in  both  arms,  and  the  toes  of  both  feet  would  "go  to  sleep." 
Sometimes  darting  pains  occurred  down  the  arm  and  one  finger. 
This  patient  had  acid  dyspepsia  and  flushings,  bilious  vomiting, 
and  thick  urine.  The  intrinsic  muscles  of  the  left  thumb  were 
less  excitable  than  those  of  the  right  to  induced  electrical  cur- 
rents, and  less  so  than  those  of  a  healthy  person.  This  lady's 
father  suffered  badly  from  gout,  and  she  had  partaken  rather  freely 
of  sherry,  and,  occasionally,  of  whisky. 

In  a  man,  set.  forty-seven,  there  was  loss  of  power  in  the 
thumb  and  first  two  fingers  of  the  left  hand.  There  was  inability 
to  flex  the  phalanges  of  the  thumb,  index  and  middle  fingers 
(except  the  first).  The  forearm  had  wasted.  "  Pins  and  needles  " 
were  constantly  felt  in  the  fingers,  and  the  parts  were  hyper - 
sesthetic  to  touch,  pressure,  heat,  cold,  and  pain.  There  was 
defective  reaction  to  faradic  currents  in  the  thumb-muscles.  To 
the  galvanic  current  applied  to  the  musculo-spiral  nerve  above 
the  elbow  A.C.O.  was  =  to  K.C.C.,  and  the  opening  contraction 
with  the  kathode  was  equal  to  that  with  the  anode.  The  supi- 
nator longus  muscle  was  unaffected.  The  nerves  implicated  were 
the  branches  of  the  median  supplied  to  the  palm  and  first  three 
fingers,  as  well  as  to  the  opponeus,  abductor,  and  flexor  brevis 
pollicis,  the  cutaneous  branches  of  the  radial  distributed  to  the 
1  Paralysis  from  Peripheral  Neuritis,  p.  25,  1886. 


NEURITIS.       PHLEBITIS.  307 

dorsal  surface  of  the  thumb  and  two  outer  fingers,  and  the 
internal  cutaneous  branch  of  the  musculo-spiral.  There  was  no 
history  of  exposure  to  cold  or  pressure.  The  man's  habits  were 
believed  to  be  conducive  to  gout. 

The  amyotrophy  in  these  cases  is  probably  of  the  reflex  char- 
acter peculiar  to  arthritic  muscular  atrophy. 

Dr.  Buzzard  relates  other  cases,  and  in  some  there  was  clear 
history  of  gout,  and  relief  from  treatment  directed  accordingly.1 
In  one  case  puffy  swelling  occurred  in  the  arm,  and  some  herpes. 

In  some  of  them  the  involvement  of  vaso-motor  branches  was 
plainly  manifested,  there  being  coldness  and  discoloration  of  the 
skin.  The  character  of  the  disorder,  and  especially  the  electrical 
changes,  point  clearly  to  neuritis  as  the  exact  cause  of  the  special 
symptoms. 

Difficulty  in  diagnosis  may  occur  in  cases  with  history  of 
alcoholic  habits,  where  the  prevailing  conditions  are  such  as  to 
induce  neuritis  of  either  the  gouty  or  the  alcoholic  variety.  In 
my  experience  the  latter  cases  occur  more  frequently  in  women 
under  forty  years  of  age  who  are  not  gouty,  than  in  men. 

I  have  known  puffiness  of  the  hand  and  glossy  fingers  to  occur 
in  these  cases,  together  with  marked  lameness  and  clumsiness  of 
the  involved  digits.  Pye-Smith  records  an  example  which  came 
on  soon  after  an  attack  Of  gout  involving  the  hands  and  feet,  and 
which  subsided  without  treatment.2 

Saturnine  neuritis,  which  is  sometimes  one-sided,  may  occur  in 
connection  with  gout. 

Gouty  Phlebitis. 

The  characters  of  this  disorder  have  been  fully  described,  first 
by  Sir  James  Paget 3  in  1 866,  afterwards  by  Sir  Prescott  Hewett 4 
and  Dr.  Tuckwell.5  Its  pathological  position  is  amongst  the  many 
forms  of  imperfect  or  incompletely  developed  gout. 

The  disorder  very  markedly  occurs  in  persons  of  gouty  heritage, 
or  whose  habits  of  life  have  led  to  the  acquirement  of  the  gouty 
state. 

The  veins  of  the  lower  extremities  are  most  frequently  involved, 
but  those  of  the  upper  extremities,  as  high  as  the  subclavian,  may 
sometimes,  though  rarely,  be  affected.      The  saphena  and  its  tri- 

1  Brit.  Med.  Journal,  December  2,  1876. 

2  Fagge's  Prin.  and  Prac.  of  Medicine,  2nd  edit.,  vol.  i.  p.  432,  1888. 

3  St.  Barth.  Hosp.  Reports,  vol.  ii.,  1866,  p.  82. 

4  Clin.  Soc.  Trans.,  vol.  vi.,  1873,  p.  xxxvii. 

6  St.  Barth.  Hosp.  Reports,  vol.  x.,  1874,  p.  23. 


o 


08  VISCERAL    GOUT,    ETC. 


butaries  in  the  calves  have,  so  far  as  I  have  seen  examples,  been 
more  often  implicated  than  any  other  branches.  The  trouble  may 
begin  quietly,  or  sometimes  with  pain  in  the  part,  which  may 
continue  more  or  less  severe  for  weeks  or  months,  or  a  little 
itching  or  uneasiness  may  be  all  that  is  experienced,  and,  on 
examination,  a  cord-like  hardness  is  found  already  established. 

There  is  a  tendency  for  the  inflammatory  process  to  spread 
along  the  branch  first  affected,  also  for  other  veins  to  be  affected 
at  some  distance,  so  that  there  is  sometimes  present  what  may  be 
termed  patchy  phlebitis.  In  one  case  of  this  kind  under  my 
care,  there  was  excruciating  pain  with  each  fresh  attack.  I 
regard  the  trouble  as  a  localized  form  of  specific  gouty  inflamma- 
tion, affecting  the  coats  of  the  vein,  leading  to  roughening  of  the 
internal  lining,  and  so  favouring  thrombosis.  The  condition  of 
the  system  at  the  time  is  essentially  gouty,  and  with  this  there  is 
hyperinosis  or  ready  tendency  for  the  blood  to  clot.  There  may 
be  assumed  to  be  a  determination  of  acid  urates  to  the  part  as 
the  directly  exciting  cause.  Other  gouty  manifestations  may  be 
associated  with  the  local  change,  and  acute  gout  may  have  already 
occurred,  or  may  follow  at  later  periods. 

Traumatism  plays  a  part  in  some  cases  in  bringing  on  this 
trouble,  and  trifling  provocation  may  suffice  to  determine  the 
part  affected.  Blows,  continued  friction,  or  undue  muscular 
exertion  may  thus  be  causes.  Exposure  to  cold  after  being 
heated  has  been  alleged  as  an  excitant,  but  I  have  no  experience 
of  this. 

The  most  serious  cases  are  those  in  which  a  large  vein  is 
involved,  such  as  the  femoral  or  the  subclavian. 

With  ordinary  care  the  involvement  of  small  vessels  is  of  little 
moment.  Superficial  veins  are  more  apt  to  suffer  than  those 
situated  deeply,  probably  because  more  exposed  to  injuries,  and 
no  appreciable  dropsy  is  observed  in  these  cases.  In  the  event 
of  the  deeper  and  larger  veins  being  involved,  considerable 
oedema  (oedema  durum)  of  the  parts  below  ensues  on  the  estab- 
lishment of  thrombosis,  the  limb  being  pale,  with  dilatation  of 
the  superficial  veins. 

Renewed  attacks  in  other  veins  may  follow,  and  relapses  are 
unfortunately  frequent  on  trifling  provocation.  One  of  the  com- 
monest causes  of  relapse  is  a  too  early  return  to  use  of  the  affected 
limb. 

The  gravest  risk  in  any  case,  but  especially  in  those  impli- 
cating the  deep  and  larger  veins,  is  that  of  detachment  of  the 
thrombus  or  part  of  it,  and  its  carriage  into  the  pulmonary  artery 


PHLEBITIS.  309 

or  one  of  the  lungs.  Several  fatal  cases  from  this  accident  are 
on  record ;  but  they,  happily,  do  not  often  occur  if  strict  pre- 
cautions are  maintained  throughout  the  progress  of  the  disorder. 
The  clot  itself  is  apt  to  be  very  firm,  and  also  intimately  attached 
to  the  venous  wall. 

On  inspection,  there  may  be  seen,  at  first,  slight  redness  or  blush 
over  the  affected  vein.  Deeper  veins,  if  blocked,  may  not  be 
palpable,  but  pain  or  oedema,  or  both,  declare  the  nature  of  the 
disturbance.  The  ordinary  termination  is  by  resolution,  with, 
presumably,  tunnelling  of  the  clot,  a  process  occupying  from  two 
to  three  months,  or  much  longer,  or  by  occlusion  of  the  venous 
branch.  In  some  other  forms  of  phlebitis,  such  as  are  due  to 
traumatism,  for  instance,  an  earlier  restoration  to  a  healthy  state 
may  be  expected.  Suppuration  does  not  occur,  this  result  being 
infinitely  rare  as  the  outcome  of  gouty  inflammatory  process  in 
any  part.  If  occlusion  of  an  important  branch  occurs,  the  limb 
thereafter  remains  slightly  puffy  and  heavy,  with  compensatory 
enlargement  of  superficial  veins. 

Recurrent  Phlebitis. — When  superficial  veins  are  involved,  they 
are  very  apt  to  be  attacked  again,  and  often  remain  tender  and 
sensitive.  I  have  known  the  same  branch,  a  tributary  of  the 
saphena,  to  be  affected  five  or  six  times  at  varying  intervals, 
friction  from  stirrup-leathers  while  riding,  and  hard  walking, 
being  the  direct  excitants  of  the  attacks.  Recurrence  of  phle- 
bitis is  very  common. 

Women  are  rarely  the  subjects  of  gouty  phlebitis,  though  in 
cases  of  atonic  and  incomplete  gout  they  may  suffer  from  a  re- 
current form  of  it.  Paget  quotes  the  experience  of  Sir  Charles 
Locock  in  respect  of  four  sisters  who  had  phlegmasia  dolens,  and 
whose  father  had  crural  phlebitis. 

This  manifestation  of  gout  is  believed  by  Paget  to  be  of  com- 
paratively recent  occurrence.  Sir  Henry  Halford  described  cases 
of  what  he  called  phlegmasia  dolens  in  the  male,  due  to  inflam- 
mation of  veins  of  the  pelvis.1  Paget  believes  that  a  disorder 
so  obvious  as  phlebitis  could  hardly  have  escaped  recognition 
and  description,  had  it  been  as  commonly  met  with  as  now.  "  So 
we  may  believe,"  he  states,  "  that  the  disease  has  become  more 
frequent  in  the  last  fifty  years,  and  may  suspect  that  not  long 
before  Sir  Henry  Halford's  time  it  may  have  been  a  really  new 
disease."  He  conceives  that  this  disease  is  "  amongst  the  instances 
of  the  results  of  morbid  conditions  changing  and  combining  in 

1  Paper  read  before  Roy.  Coll.  of  Physicians,  April  1832.     Essays  and  Orations, 
3rd  edit.,  Lond.,  1842.     Essay  viii.,  p.  121. 


3IO  VISCERAL    GOUT,    ETC. 

transmission  from  parents  to  offspring."  1     He  regards  it,  there- 
fore, as  a  new  modification,  outcome,  or  transformation  of  gout. 

Dr.  Edward  Liveing  has  kindly  given  me  the  following  notes 
of  two  important  cases,  which  well-illustrate  this  form  of  phle- 
bitis, and  afford  convincing  evidence,  if  such  were  needed,  of  the 
truly  gouty  nature  of  it. 

Case  I. — A.  C.  was  the  rector  of  a  country  parish,  a  middle-aged  bachelor, 
living  a  very  retired,  routine  life.  He  was  of  stout  build,  tending  to  corpulency  ; 
was  accustomed  to  much  standing  about  out  of  doors,  but  little  active  exercise  ; 
was  moderate,  but  not  abstemious  in  his  habits.  This  gentleman  belonged  to  a 
gouty  stock,  his  mother  and  maternal  uncles  developing  some  of  the  many  forms 
of  the  malady,  though  of  a  mild  kind.  One  of  his  brothers  suffered  from  granular 
kidney  with  great  cardiac  hypertrophy,  and  ultimately  fatal  cerebral  haemorrhage  ; 
several  of  his  nephews  and  great-nephews  from  mild  arthritic  attacks,  gouty 
nodules,  severe  migraines,  and  other  forms  of  irregular  gout.  One  of  them  is  the 
subject  of  the  second  case. 

A.  C.  enjoyed  fairly  good  health  until  past  fifty  years  of  age,  having  rarely 
missed  his  duty.  He  had  been  in  the  habit  of  taking  pretty  frequent  doses  of 
blue  pill  and  colocynth  "  for  his  liver,"  as  he  said.  He  never  had  a  typical 
attack  of  acute  gout  in  foot  or  hand,  but  when  about  fifty-five  began  to  suffer 
from  subacute  attacks  in  his  heels  and  ankles  and  the  tendons  about  them,  lead- 
ing in  the  end  to  much  thickening  and  enlargement,  and  reducing  his  exercise 
still  further.  He  was  also  greatly  troubled  by  a  general  gouty  pruritus,  without 
visible  eruption,  and  only  relieved  by  brushing. 

When  about  sixty-five  he  was  suddenly  attacked  with  phlebitis  or  phlegmasia 
dolens  in  the  right  leg.  The  deeper  veins  were  involved,  and  there  was  great 
enlargement  of  the  whole  limb,  of  india-rubber-like  consistence,  and  in  every  way 
characteristic  of  the  gouty  form.  While  he  was  still  confined  to  bed,  the  left  limb 
was  similarly  attacked.  The  whole  character  and  course  of  the  malady  were 
quite  typical,  and  recalled  the  then  recent,  but  now  classical,  description  in  Sir 
James  Paget's  Essays.  Recovery  was  slow,  and  the  limbs  never  regained  their 
proper  size,  and  walking  was  more  difficult  than  ever.  It  was  nearly  six  months 
before  he  could  resume  his  duty. 

At  or  about  the  time  of  this  attack  attention  was  drawn  to  the  state  of  the 
pulse,  which  had  become  extremely  irregular.  Before  that  it  had  been  slow,  soft, 
full ;  it  may  have  been  occasionally  intermittent,  but  nothing  more.  Tension 
was  low,  and  no  rigidity  of  vessels.  But  from  this  time  the  derangement  of 
rhythm  was  most  extraordinary,  and  may  perhaps  be  rudely  represented  thus : — 


and  so  on. 


This  continued  with  some  variation  to  the  end  of  his  life,  some  ten  years  later. 
Meanwhile  he  had  no  particular  illnesses,  and,  except  for  occasional  attacks  of 
faintness  and  one  or  two  severe  nose-bleedings,  which  alarmed  him,  and  feebleness, 
he  was  fairly  well.  There  was  never  a  trace  of  albumen  in  the  urine  nor  any  renal 
trouble.  The  cardiac  impulse  was  feeble,  diffused,  and  often  difficult  to  fix,  and 
the  sounds  were  feeble  and  very  much  alike.  There  was  never  any  bruit  audible. 
We  suspected  a  flabby  thin  left  ventricle. 

1  "On  Some  Rare  and  New  Diseases,"  Bradshaw  Lecture,  Roy.  Coll.  of  Surg., 
1882,  p.  13. 


PHLEBITIS.  3  I  I 

He  did  his  duty  to  the  end,  though  with  considerable  difficulty,  owing  to  the 
unwieldy  state  of  his  legs  and  the  tendency  of  the  skin  to  inflame. 

Without  warning,  the  circulation  was  suddenly  arrested  in  the  left  leg,  to  such 
an  extent  that  it  became  quickly  gangrenous  up  to  the  knee.  About  a  week  later 
he  had  a  slight  cerebral  seizure — some  twitching  of  the  face,  followed  by  a  coma- 
like sleep,  from  which  he  awoke  with  embarrassed  speech  and  weakness  of  the 
right  side.     The  following  week  he  died  without  fresh  symptoms. 

Case  II.  is  that  of  B.  D.,  a  nephew  of  the  former,  and  also  a  country  clergy- 
man. He  was  of  a  very  different  build  and  temperament  from  his  uncle, 
being  tall  and  spare,  and  soured  by  ill-health.  From  his  college-days  he  had 
suffered  from  persistent  dyspepsia,  with  exacerbations  from  time  to  time  so 
severe  as  to  make  feeding  difficult.  He  was  consequently  compelled  to,  and  did, 
live  for  thirty-five  years  a  very  abstemious  life.  Alcohol  in  any  form  and  fruit 
and  vegetables  were  literally  poisonous  to  him,  and  so  were  all  made  dishes  and 
sweets,  and  indeed  everything  but  the  plainest  food.  His  diet  was  one  of  bread 
and  some  form  of  animal  food,  chiefly  mutton,  with  milk  and  rice  and  similar 
puddings.  His  malady  was  very  much  what  has  been  described,  with  doubtful 
propriety,  as  "eczema  of  the  stomach."  He  became  a  martyr  to  physic,  ortho- 
dox and  otherwise,  in  the  hope  of  relief,  which  he  never  obtained. 

When  about  the  age  of  thirty-eight,  he  gave  up  his  living  on  inheriting  a 
country  estate,  and,  hoping  the  change  might  do  him  good,  he  lived  for  nearly 
thirty  years  an  outdoor  agricultural  life,  but,  unfortunately,  with  little  benefit. 

I  remember  his  consulting  me  some  years  later,  during  one  of  the  longest  and 
severest  of  his  bouts  of  illness.  He  then  presented  very  much  the  aspect  of  a 
patient  with  a  malignant  disease  of  the  stomach — greatly  emaciated,  features 
nipped,  and  complexion  sallow,  with  much  gastric  pain  and  distress.  I  had  my 
suspicions,  but  kept  them  to  myself.  In  time  he  got  better,  and  recovered  his 
usual  amount  of  health. 

When  about  the  age  of  fifty- six,  he  developed  eczema  of  both  palms,  and  to  a 
less  extent  of  the  groins,  which  continued  to  trouble  him  for  many  years.  But 
from  this  time  the  gastric  troubles  greatly  abated,  and  for  the  last  ten  years  of 
his  life  he  was  able  to  take  wine  and  other  stimulants,  and  a  much  greater 
variety  of  food,  including  fruit  and  vegetables. 

Among  the  occurrences  of  this  period,  I  remember  a  temporary  goitre,  which 
lasted  a  year  or  more,  and  transient  prostatic  troubles.  There  was  never  any 
albumen  or  renal  affection. 

When  about  the  age  of  sixty-six,  severe  inflammation  was  set  up  in  the  second 
toe  of  one  foot,  apparently  from  so  trivial  a  cause  as  cutting  a  corn.  For  a  time 
the  toe  threatened  to  slough,  but  ultimately  healed,  though  not  very  soundly. 

He  was  now  suddenly  attacked  with  gouty  phlebitis,  and  the  characteristic 
enlargement  of  the  legs,  very  much  as  his  uncle  had  been,  though  less  severely. 
He  was  in  bed  many  weeks  and  recovered  ;  but  though  the  swelling  of  the  legs 
went  down,  they  remained  almost  useless  to  him,  and  he  had  to  be  carried  up  and 
down  stairs,  and  lifted  in  and  out  of  his  chaise. 

During  this  illness  my  attention  was  drawn  to  the  state  of  the  pulse,  which  had 
become  very  nearly  as  irregular  and  intermittent  as  his  uncle's,  and  without  any 
indications  of  heart-disease  except  feebleness.  A  troublesome  ulcer  now  formed 
over  one  ankle,  which  his  medical  attendant  called  gouty,  and  which  would  not  heal. 

The  following  winter,  while  driving  out  as  usual,  he  was  supposed  to  have  had 
one  foot  chilled,  for  the  great-toe  became  gangrenous ;  and  in  the  course  of  the 
next  two  months  the  gangrene  extended  to  the  leg,  and  brought  him  to  his  end. 

Gangrene. — In  cases  of  chronic  gout,  with  much  debility  and 
feeble  circulation,  gangrene  of  the  extremities  may  occur.      It  is 


312  VISCERAL    GOUT,    ETC. 

a  rare  condition,  and  the  direct  association  with  gout  is  hardly 
demonstrable.  The  foot  is  commonly  the  part  affected,  but  both 
feet  may  suffer  simultaneously.  The  form  of  gangrene  is  dry. 
Carmichael,  of  Dublin,  recorded  an  example  in  a  gentleman  be- 
tween sixty  and  seventy  years  of  age,  subject  to  gout.1  The 
gangrene  spread  up  from  the  left  second  toe  to  below  the  knee. 
Gasping  respiration  set  in  and  delirium.  The  pulse  was  irre- 
gular, and  none  was  felt  in  the  iliac  artery  of  the  affected  side. 
Later,  none  was  detected  in  that  of  the  opposite  side.  At  the 
autopsy  the  heart  was  found  softened  and  fatty,  aortic  valves 
slightly  ossified.  The  left  iliac  artery  was  plugged  with  a  fibri- 
nous clot,  which  was  breaking  down.  Both  femoral  arteries  were 
also  sealed  by  fibrin.  The  saphena,  iliac,  and  renal  veins  were 
blocked  by  coagula.  The  order  of  events  in  cases  of  this  nature 
is  as  follows : — A  chronic  gouty  state  leading  to  cachexia,  with 
degenerative  changes  in  the  heart  and  arteries,  induces  at  last 
such  a  feeble  state  of  circulation  that  arterial  and  venous  throm- 
bosis sets  in ;  or,  from  valvular  degenerations,  fibrinous  emboli 
may  be  shed  into  distant  arteries.  In  such  cases  the  kidneys  are 
presumably  unsound  from  chronic  interstitial  nephritis.  In  other 
cases  there  may  have  long  been  glycosuria  connected  with  the 
gouty  habit,  under  which  circumstances  gangrene  is  somewhat 
prone  to  occur.  Arterial  atheroma  is  not  always  present  in 
marked  degree  in  these  cases. 


Orbital  Cellulitis  and  Suppuration  of  the  Eyeball  in 
Persons  of  Gouty  Habit. 

Two  cases  of  relapsing  double  orbital  cellulitis  of  probable 
gouty  origin  have  been  recorded  by  Mr.  Nettleship.2  In  one  the 
patient  was  a  man  aged  forty-four  years.  He  was  very  gouty, 
and  had  suffered  from  two  attacks  annually  for  twelve  years. 
Seven  years  previously  he  had  had  chemosis  and  acute  orbital 
periostitis.  In  the  other  case,  also  in  a  man  aged  thirty-five 
years,  there  was  double  orbital  cellulitis,  temporary  iridoplegia, 
and  amblyopia.  His  father  was  a  painter,  and  never  free  from 
gout.      There  was  no  proof  of  syphilis. 

The  symptoms  were  symmetrical,  including  proptosis,  redness 
and  swelling  of  ocular  conjunctivae  and  eyelids.  The  right  side 
was  the  more  involved.     The  affection  had  lasted  for  three  weeks. 

1  Dublin  Med.  Journal,  vol.  ii.,  1846,  p.  233. 

2  St.  Thomas's  Hospital  Reports,  vol.  xi.  p.  9,  1882. 


AMYOTROPHY.  313 

The  roof  of  each  orbit  was  thickened.  Vision  was  impaired, 
whether  from  failure  of  accommodation  or  from  disease  of  the 
optic  nerves  was  not  determined.  Mr.  Nettleship  believed  that 
the  ciliary  nerves  were  involved.  There  was  perfect  recovery. 
Mr.  Critchett  described  an  instance  of  suppuration  of  the  eyeball, 
which  occurred  in  a  case  of  chronic  gout  in  a  man.1 


Gouty  Amyotrophy. 

Amongst  the  local  disorders  due  to  gouty  arthritis  when  of 
long  duration  is  some  degree  of  muscular  atrophy.  This  impli- 
cation of  the  muscles  is  not  peculiar  to  gout,  but  is  well- 
recognized  as  a  result  of  chronic  arthritis  from  any  cause. 

Minor  degrees  of  wasting  occur  in  connection  with  paroxysmal 
gout  of  short  duration,  but  are  hardly  recognized  till  several 
attacks  have  involved  a  joint.  They  are  naturally  most  marked 
in  the  case  of  the  knee,  wrist,  and  elbow.  The  causation  is  the 
same  in  all  cases,  a  reflex  atrophy  due  to  changes  in  the  nerve- 
centres,  which  are  irritated  by  the  painful  state  of  the  nerves 
supplying  the  affected  joint.  The  painful  sensory,  centripetal, 
impressions  modify  the  trophic  conditions  of  the  centre,  and 
lead,  refiexly,  to  impaired  nutrition  of  the  associated  muscles  of 
the  part. 

Mere  disease  of  the  joints  is  insufficient  of  itself  to  induce  the 
degree  of  muscular  wasting  which  occurs.  The  gravity  and  per- 
manence of  the  atrophy  is  accurately  determined  by  that  of  the 
articular  trouble,  and  if  the  latter  is  amenable  to  treatment,  the 
wasting  may  be  recovered  from,  sometimes  completely. 

This  condition  of  arthritic  amyotrophy  may  follow  on  earlier 
muscular  involvement,  manifesting  itself  in  disturbance  of  motor 
influences,  which,  by  inducing  reflex  spastic  states,  may  lead  to 
deflections  of  digits  and  other  parts,  as  already  explained  in  an 
earlier  chapter. 

A  well-marked  example  of  muscular  wasting  consecutive  to 
acute  articular  gout  is  recorded  by  M.  Cornillon,  of  Vichy.2  The 
patient  was  a  male,  set.  fifty-five,  who  suffered  from  several 
attacks  of  biliary  colic.  He  had  had  acute  gout  in  the  right 
shoulder  and  wrist  two  winters  in  succession,  suffering  extreme 
pain,  and  consequent  immobility  of  the  limb.  The  feet  were  not 
affected.  There  was  a  tophus  in  the  right  ear,  atrophy  of  the  del- 
toid, extensors  of  the  fore-arm,  thenar  and  hypothenar  eminences, 

1  Medical  Times,  vol.  i.  p.  62,  1858. 

2  Progres  Medical,  Mai  26,  1883,  p.  105. 


314  VISCERAL    GOUT,    ETC. 

and  interossei  muscles.  The  hand  was  griffon-like.  There  was 
diminished  contractility  to  galvanism  in  many  of  the  affected  mus- 
cles. Pain  was  felt  at  the  level  of  the  seventh  cervical  vertebra. 
The  late  Dr.  Theophilus  Thompson  regarded  as  a  distinctly 
gouty  manifestation  a  case  of  progressive  muscular  atrophy  in  one 
son  of  a  family  in  which  the  mother  was  severely  affected  with 
chronic  rheumatic  arthritis,  and  seven  brothers  were  typically 
gouty.  I  have  no  knowledge  of  any  similar  case,  and  no  syste- 
matic author  has  noted  this  connexion. 


CHAPTER  XIV. 

ON  THE  PROPRIETY  OF  SURGICAL  OPERATIONS 
ON  THE  GOUTY. 

The  fitness  of  a  gouty  subject  for  operative  interference  is  to  be 
determined  by  consideration  of  the  degree  in  which  his  textures 
suffer  from  the  degenerative  changes  induced  by  the  dyscrasia. 
Where  the  heart  and  kidneys  are  unsound,  it  would  be  unwise  to 
urge  any  operation  that  was  not  imperatively  called  for.  Fits  of  gout 
maybe  brought  on  by  operations  as  by  other  forms  of  traumatism, 
and  they  exercise  a  temporary  malign  influence  on  the  healing 
process,  but  hardly  more  than  this.  Fractures  of  bone  may  be 
delayed  in  uniting,  the  integuments  may  ulcerate  and  the  bones 
be  laid  bare,  but  all  these  troubles  subside  with  the  subsidence  of 
the  local  gout,  and  the  after-progress  is  commouly  satisfactory. 
The  operation  for  cataract  is  apt  to  fail  or  do  badly  in  the  gouty. 
Glycosuria  is  an  unfavourable  condition  for  surgical  interference, 
especially  if  pronounced  or  of  long  duration.  Incoercible  haemor- 
rhage may  result  in  such  cases.  On  the  whole,  it  may  be  laid 
down  that,  as  a  rule,  none  but  operations  of  necessity  should  be 
performed  on  the  subjects  of  marked  gouty  habit.  This  caution 
applies  to  minor  operations,  such  as  removal  of  wens  and  fatty 
tumours,  to  ligature  of  veins  and  piles,  and  even  to  puncturation ; 
and  it  is  necessary,  too,  in  spite  of  the  practice  of  all  antiseptic 
precautions,  which  may  avail  little  or  nothing  in  such  cases. 

There  is  increased  vulnerability  in  the  subjects  of  chronic 
gout,  and  my  own  experience  leads  me  to  state  that  even  trifling 
injuries  may,  sometimes,  induce  erysipelas,  destructive  cellulitis, 
and  gangrene.  A  caution  against  nimia  diligentia  may  be  some- 
times as  necessary  for  chirurgus  as  for  medicus,  and  truly,  in 
mauy  phases  of  disease,  abstention  from  interference  is  more 
important  than  any  line  of  action. 


CHAPTER  XV. 
ON  SOME  DISORDERS   SIMULATING  ACUTE   GOUT. 

Of  these,  I  will  refer  to  three. 

Pysemie  Arthritis. — Pyasmic  arthritis  has  before  now  been 
mistaken  for  uratic  arthritis.  The  error  is  quite  pardonable  in 
the  first  instance,  especially  if  the  patient  has  already  suffered 
from  gout.  The  diagnosis  is  not  long  undisturbed  in  such  a 
case.  Suppuration,  which  is  the  rarest  event  in  gout,  rapidly 
follows  tumefaction,  and,  if  care  be  taken,  the  original  site  of 
infectivity  may  not  be  far  to  seek.  Any  recent  operation,  as  for 
piles,  or  the  existence  of  otitis,  may  lead  to  detection  of  the 
source  of  the  arthritis. 

Acute  Necrosis  of  Bone. — Acute  necrosis  of  bone  may  set  in 
suddenly  sometimes  in  elderly  people,  and  there  may  be  a  history 
of  gout  in  the  case.  The  tibia,  fibula,  or  humerus  may  be  the 
site  of  redness,  swelling,  and  pain,  and,  so,  closely  simulate  an 
acute  attack  of  gout.  (Edema  may  ensue,  but  fluctuation  becomes 
detectible,  and  sub-periosteal  abscess  is  to  be  diagnosticated.  In 
the  more  frequently  occurring  cases  of  acute  necrosis  and  sup- 
purative epiphysitis  in  growing  boys,  the  diagnosis  of  acute  gout 
is  hardly  likely  to  be  made. 

Gonorrhceal  Rheumatism. — Gonorrhceal  rheumatism,  involving 
one  joint,  not  unfrequently  simulates  gouty  arthritis.  The  history 
and  course  of  the  disorder  guide  to  a  correct  diagnosis.  The 
likeness  here  is  the  more  interesting  because  there  is  commonly 
a  history  of  gouty  tendency,  and  patients  with  this  proclivity 
are  specially  vulnerable  to  gonorrhceal  poison.  There  may,  there- 
fore, be  a  gouty  element  in  the  case  demanding  recognition. 
The  inadequacy  of  sodium  salicylate  to  afford  relief,  and  the 
benefit  derivable  from  potassium  iodide,  quinine,  and  colchicum  in 
some  cases,  after  treating  the  urethritis,  are  also  significant  and 
noteworthy. 


CHAPTER  XVI. 

SKIN-DISEASES   IN  CONNECTION  WITH   GOUT. 

Several  varieties  of  skin-disease  are  now  well-recognized  as 
dependent  on  a  gouty  habit.     Galen  observed  this  connection. 

Pruritus-P.  Hyemalis— P.  Ani— P.  Vulvae. — Pruritus  is  noted  with 
some  frequency.  There  may  be  no  visible  lesion  associated  with 
it.  The  form  known  as  pruritus  hyemalis  is,  I  believe,  sometimes 
connected  with  gouty  predisposition,  and  anal  itching  is  often  thus 
associated.  The  latter  may,  or  may  not,  be  connected  with  a 
hemorrhoidal  state.  Alternation  of  pruritus  with  articular  gout 
has  been  noted.  Vulvar  pruritus  is  common  in  women  suffering 
from  gouty  glycosuria,  and  may  be  one  of  the  leading  symptoms 
calling  attention  to  this  state. 

I  have  known  chronic  general  pruritus  yield  completely  on 
the  supervention  of  gouty  cystitis.  This  occurred  in  an  elderly 
gentleman,  who  was  fond  of  strong  soups,  and  drank  a  good  deal 
of  sherry. 

Prurigo. — Prurigo  is  sometimes  the  outcome  of  pruritus.  In 
this  case  papular  lesions  are  induced  by  long-continued  scratching. 
In  the  old,  care  must  be  taken  to  exclude  phthiriasis.  The  pruritus 
is  primarily  neurotic,  and  due,  probably,  to  uricheemia.  It  gives 
rise  at  times  to  intolerable  suffering,  and  local  means  are  com- 
monly powerless  to  afford  relief. 

The  papules  of  prurigo  are  sometimes,  and  not  unfairly,  regarded 
as  truly  lichenous.  Uncovered  parts  of  the  body  are  not,  as  a 
rule,  affected. 

Aene. — Acne  has  been  alleged  by  some  authors  to  be  sometimes 
associated  with  a  gouty  state,  but  I  have  no  experience  of  such 
cases.  Garrod  records  a  case  where  alternation  with  articular  gout 
occurred. 

Furuneuli— Anthrax. — Furuncles  and  carbuncles  sometimes  occur 
in  gouty  persons,  the  former  in  association  with  glycosuria,  but 


318  SKIN-DISEASES    IN    CONNECTION    WITH    GOUT. 

not,  in  my  experience,  very  often.  The  nape  and  lower  lip  may 
be  seats  of  carbuncle. 

Pemphigus. — Pemphigus  is  probably  never,  or  most  rarely,  a 
manifestation  of  gout.  Uric  acid  has,  however,  been  found  in  the 
serum  drawn  from  the  bullae  in  several  instances. 

Psoriasis. — Psoriasis  is  sometimes  met  with  in  gouty  persons, 
and  may  alternate  with  articular  attacks.  Garrod,  as  the  result 
of  special  study  of  the  subject,  declares  that  psoriasis  is  not  con- 
nected with  gout,  as  is  eczema.  Cases,  however,  do  occur  in  which 
alternations  of  articular  gout,  psoriasis,  and  bronchitis  are  mani- 
fest.1 Garrod  found  that  psoriasis  was  more  frequently  associated 
with  chronic  rheumatic  arthritis,  and  that  successful  treatment  of 
the  joints  relieved  the  skin-disorder.  I  am  prepared  to  affirm  that 
the  majority  of  cases  of  psoriasis  seen  in  practice  manifest  no  direct 
connection  with  a  gouty  habit,  but  some  are  distinctly  so  related.2 

I  believe  that,  sometimes,  patches  of  dry  eczema  have  been  mis- 
taken for  those  of  psoriasis,  and,  hence,  the  latter  may  have  been 
unwarrantably  credited  with  a  dependence  on  gout. 

Dermatitis  Exfoliativa. — This  disorder,  also  known  as  pityriasis 
rubra,  is  apt  to  occur  in  members  of  arthritically  disposed  families. 
It  may  be  developed  from  psoriasis,  and  cases  of  the  latter  may 
become  examples  of  general  pityriasis  rubra.  True  gout  figures 
in  the  aetiology  of  this  disorder,  perhaps  in  one-fifth  of  the  cases, 
and  it  may  alternate  with  attacks  of  it. 

Eczema. — Eczema  is,  without  doubt,  the  type  of  skin-disease 
most  directly  connected  with  the  gouty  habit.  This  is  true  of 
all  forms  of  the  disorder,  and  to  find  the  true  relationship  here, 
it  is  necessary  to  be  familiar  with  the  many  phases  of  eczema. 
Garrod's  researches  affirm  most  pointedly  the  intimate  connection 
between  gout  and  eczema.3  He  found  that  the  latter  was  prone 
to  affect  the  following  parts,  in  the  order  of  frequency  mentioned  : 
the  ears  externally,  within  the  meatus  and  behind  the  auricle, 
the  nape  of  the  neck,  eyelids  and  face,  groins,  and  flexures  of 
other  joints,  scrotum,  glans  penis,  and  prepuce,  backs  of  hands 
and  feet,  interdigital  surfaces,  arms  and  legs,  and  various  portions 
of  the  trunk.  It  is  commonly  symmetrical  on  both  sides  of  the 
body. 

Garrod  found  that  eczema  may  precede  overt  gouty  attacks  by 

1  Greenhow  has  reported  several  examples.      Op.  cit.,  p.  148. 

2  I  have  notes  of  two  cases  in  which  gout  with  tophi  in  the  ears  occurred  in  men 
long  subject  to  typical  psoriasis,  and  of  one  in  a  woman  with  tophaceous  gout,  who 
died  of  carcinoma  of  the  liver,  following  the  same  disease  in  the  mamma.  She  had 
psoriasis  guttata. 

3  Trans.  Internat.  Med.  Congress,  London,  18S1,  p.  102. 


ECZEMA.  319 

many  years,  and  attack  patients  whose  whole  history  was  gouty, 
but  who  had  never  suffered  from  arthritis ;  also,  that  it  may 
occur  late  in  a  gouty  life,  even  in  extreme  old  age,  when  fits  of 
ordinary  gout  have  become  much  less  frequent  and  less  severe. 

Acute  eczema  may  replace  an  articular  attack.  In  gouty 
families,  a  parent  may  have  arthritis,  one  son  ordinary  gout,  and 
another  eczema  without  arthritis.  It  may  attack  the  females 
in  such  families  about  the  menopause,  true  gout  supervening 
after  that  period. 

Garrod  believes  that  eczema  occurs  in  about  thirty  per  cent,  of 
cases  of  gout  of  long  duration. 

The  disorder  in  its  acute  stage  is  apt  to  cause  much  distress 
and  suffering  from  extreme  itching  and  burning  sensations.  In 
the  chronic,  dry  form,  the  itching  is  sometimes  very  severe, 
indiscretions  in  diet  quickly  arousing  great  irritability  in  the 
patches.  Urticaria  may  be  occasionally  associated  with  it,  adding 
much  to  the  torment. 

Dry  patches  of  eczema  in  goutily  disposed  persons  may  remain 
present  for  weeks  in  a  quiescent  state.  I  have  notes  of  a  case  of 
incomplete  gout  where  this  condition  occurred,  and  irregular  action 
of  the  heart  supervened.  When  the  eczema  became  active  and 
recommenced  to  itch,  the  heart  became  regular  in  its  action. 
Beyond  the  irregular  cardiac  rhythm  there  were  no  other  troubles 
of  the  circulation,  and  while  it  lasted  active  exercise  was  possible 
without  any  inconvenience.  This  alternation  was  observed  on 
several  occasions.  Severe  attacks  are  apt  to  occur  in  spring- 
time, and  exposure  to  cold  north-east  winds  may  provoke  them. 

Metastasis  of  gouty  eczema  has  been  suspected  with  good  reason 
in  cases  where  asthma  or  acute  cystitis  have  supervened  on  its 
disappearance,  constituting,  in  the  language  of  the  French  school, 
a  veritable  enanthem.1 

There  is  a  great  tendency  for  gouty  eczema  to  recur.  I  have 
known  it  come  out  annually  in  symmetrical  fashion  on  both  fore- 
arms. In  another  case  it  returned  five  times  at  intervals  of  two 
years,  lasting  about  two  months  on  each  occasion,  gouty  attacks 
occurring  in  the  intervals. 

1  "  I  saw  once  a  gentleman  of  an  active,  stout  habit  of  body,  who,  having  applied  a 
piece  of  ice  cut  to  the  shape  of  his  gouty  foot,  rid  himself  indeed  very  soon  of  the  pain, 
but  in  a  little  after,  a  filthy  herpes  broke  out  all  over  his  face,  and  taking  possession 
of  his  very  eyelids,  occasioned  the  greatest  uneasiness,  from  which  I  had  scarcely  got 
him  free,  when  a  sharp  fit  of  the  gout  quickly  succeeded." — van  Swieteris  Comment, 
on  Boerhaave's  Aphorisms,  vol.  xiii.  p.  160. 

I  think  this  was  probably  an  attack  of  eczema  induced  by  gouty  retrocedence  from 
the  foot. 


320  SKIN-DISEASES   IN    CONNECTION   WITH    GOUT. 

In  saturnine  gout  cutaneous  manifestations  are  rarely  met  with, 
possibly  because  of  the  associated  spangemia  and  diminished  ner- 
vous energy  in  such  cases. 

Urticaria. — Urticaria  is  sometimes  markedly  dependent  on 
the  gouty  habit.  It  may  precede,  by  shorter  or  longer  periods, 
a  paroxysmal  attack  of  gout.  In  the  same  patient  either  gout  or 
urticaria  may  supervene  after  errors  of  diet.  Uric  acid  is  pro- 
bably the  direct  excitant,  acting  as  bile  and  other  irritants  are 
apt  to  do  in  inducing  this  disorder.  Urticaria  and  eczema  may 
co-exist  at  the  same  time  in  gouty  persons. 

There  is  nothing  specific  in  the  form  of  urticaria  associated 
with  gout.  The  fugitive  and  persistent  varieties  of  it  may  occur, 
and  so  may  the  metastases  recognized  as  peculiar  to  it. 

The  relation  of  erysipelas  to  the  gouty  habit  has  been  already 
discussed  in  Chapter  ix.,  p.  209. 

Herpes— H.  Zoster. — Herpetic  attacks,  in  all  varieties,  are 
common.  Shingles  has  been  noted  in  cases  of  gouty  glycosuria. 
Labial  herpes  is  especially  frequent  in  the  simple  catarrhal  states 
of  those  goutily  disposed.  Parts  the  site  of  former  injuries  may 
become  subject  to  recurring  herpetic  attacks,  and  these  may  occur 
as  a  form  of  retrocedent  gout  on  exposure  to  cold  and  damp  before 
an  articular  attack  has  completely  subsided.  Shingles  may  co- 
exist with  paroxysmal  gout.  The  severest  form  of  herpes — H. 
ophthalmicus  or  H.  frontalis — I  have  not  met  with  in  association 
with  gout.  Cases  are  recorded  where  it  occurred  in  "  rheumatic  " 
subjects. 

Fugitive  Gouty  Inflammation. — Graves  records  a  remarkable 
case  of  fugitive  inflammation  which  occurred  in  a  man  who  had 
had  various  phases  of  gout,  including  gastric  attacks.  On  the 
cessation  of  the  latter  the  face  began  to  swell  at  various  points, 
beginning  at  the  forehead,  spreading  to  the  cheek  and  eyelid,  so 
as  to  close  up  the  latter,  and  to  the  lips,  the  nose  never  being 
affected.  These  tumours  appeared  on  other  parts  of  the  body. 
The  left  side  was  chiefly  involved,  and  dryness  occurred  in  the 
nostril  of  that  side.  In  a  few  hours  these  tumours  subsided,  no 
trace  of  them  being  found  the  following  day.  The  patient  believed 
that  they  sometimes  occurred  in  the  stomach ;  and  the  mouth, 
palate,  and  uvula  were  occasionally  attacked.  The  symptoms 
described  would  lead  to  the  belief  that  the  nature  of  the  disorder 
was  very  closely  allied  to  urticaria.  There  were  sensory  symp- 
toms, expressed  by  a  feeling  as  if  a  current  of  air  was  directed 
on  the  face,  then  a  sense  as  of  a  fillip  of  the  finger,  or  the  bite  of 
a  gnat,  on  the  part,  which  soon  assumed  the  character  of  a  bump. 


XANTHOMA.       XERODERMIA.  32  I 

Subcutaneous  Nodules. — These  are  certainly  met  with  most 
commonly  in  association  with  rheumatic  manifestations.  I  have 
recorded  several  instances  of  these.1 

In  a  case  of  saturnine  gout  in  a  woman,  I  witnessed  the  for- 
mation of  many  small  nodules  over  the  tibiae,2  and  in  a  case  of 
chronic  gout,  also  in  a  woman,3  small  nodules  appeared  over  the 
left  tibia,  movable,  unattached  to  the  periosteum,  and  grating 
when  rubbed  against  the  bone. 

It  is  noteworthy  that  while  in  the  rheumatic  cases  the  occur- 
rence of  these  nodules  uniformly  betokens  a  slowly  progressive 
cardiac  valvulitis,  in  neither  of  these  (gouty)  cases  was  there  any 
such  disease. 

iEstus  volatieus.  — Flushing  of  the  face  in  paroxysms  is  recorded 
by  Graves  in  the  case  of  an  elderly  gouty  lady.  The  attacks 
came  on  daily  at  three  o'clock,  the  nose  becoming  hot,  bright 
red,  and,  later,  purple,  the  redness  spreading  to  the  cheeks, 
accompanied  with  uneasiness  but  not  with  pain.  This  always 
passed  off  about  the  same  hour  in  the  evening.  Minor  attacks 
of  this  disorder,  which  represent  a  vaso-motor  neurosis  of  the 
skin,  are  termed  cestus  volatieus. 

Xanthoma. — Mr.  Hutchinson  has  recorded  a  case  of  xanthoma 
which  occurred  in  a  Hebrew,  set.  forty-four,  a  man  of  dark  com- 
plexion, who  lived  freely.  He  inherited  gout,  and  had  been  sub- 
ject to  attacks  of  it  for  twenty  years.  His  father  and  maternal 
grandfather  had  suffered,  like  himself,  from  xanthoma  of  the 
eyelids. 

In  this  case,  the  patches  followed  an  attack  of  jaundice  pro- 
duced eighteen  years  previously  by  severe  fright.  There  were 
numerous  painless  and  symmetrical  enlargements  of  many  tendons, 
also  bursal  enlargements.  Over  a  swelling  on  the  right  olecranon 
were  streaks  of  xanthoma.  Exostoses  (lipping)  were  also  present 
on  the  ulnae  and  tibiae.      No  uratic  tophi  were  detected.4 

Xerodermia. — I  have  notes  of  a  case  of  xerodermia  which 
occurred  in  a  boy  aged  ten  years,  whose  maternal  grandfather 
had  "  chalky  "  gout.  The  mother  presented  several  plain  indica- 
tions of  the  arthritic  diathesis.  I  am  not  aware  that  any  con- 
nexion has  ever  been  made  out  between  gouty  inheritance  and 
this  form  of  skin-disorder,  and  simply  record  the  case  as  one  of 
interest  to  future  observers.      I  have  related  another  example  on 

1  Clin.  Soc.  Trans.,  vol.  xvi.,  1883. 

2  Clin.  Soc.  Trans.,  vol.  xx.,  1887,  and  p.  170  of  this  treatise. 

3  Vide  Fig.  13,  p.  81,  depicting  the  fingers  of  this  woman. 

4  Lancet,  April  20,  1889. 

X 


32  2  SKIN-DISEASES    IN    CONNECTION    WITH    GOUT. 

p.  400,  where  xerodermia  occurred  in  a  case  of  diabetes  in  the 
son  of  a  gouty  man.  A  brother  of  the  patient  also  suffered  from 
the  same  cutaneous  disease. 

The  implication  of  the  skin  in  cases  of  gouty  habit  is,  I  con- 
ceive, determined  by  some  inherent  weakness  or  special  predis- 
position in  the  part.  Were  this  not  so,  skin-affections  would 
probably  be  even  more  common  than  they  are  in  the  gouty. 

Some  persons  appear  to  enjoy  immunity  from  any  form  of  der- 
matitis, whatever  be  the  constitutional  provocation,  while  others 
are  only  too  prone  to  be  thus  affected. 


CHAPTER   XVII. 

GOUT  IN  WOMEN,  IN  EARLY  AND  IN  ADVANCED 

LIFE. 

"  The  arthritic  diathesis  and  cachexia,  as  manifested  in  woman, 
have  never  received  the  attention  they  deserve."  This  was 
declared  five-and-twenty  years  ago  by  Laycock,  and  he  believed 
the  omission  arose  from  a  fundamental  mistake  in  pathology,  viz., 
that  they  occurred  but  seldom  in  the  sex.  It  is  questionable 
whether  gouty  manifestations  are  now  more  common  in  women 
than  was  formerly  the  case.  The  late  Sir  Robert  Christison  told 
me  he  thought  women  manifested  more  gout  in  his  time  than  in 
that  of  Gregory,  and  he  believed  the  cause  to  be  that  women 
lived  more  highly  than  formerly.  In  the  height  of  luxury  in 
Rome  under  the  Empire,  women  suffered  from  gout. 

It  is  certain  that  women  occasionally  present  all  the  symptoms 
of  classical  and  paroxysmal  gout,  but  such  cases  are  rare.  Young 
women  may  suffer  in  this  way.  I  have  known  of  cases  occurring 
under  twenty  years  of  age,  but  they  are  infinitely  rare  before 
that  period.  W.  Gairdner  declared  that  he  had  met  repeated 
instances  of  paroxysmal  gout  in  very  young  girls.  Hippocrates 
noted  the  immunity  from  gout  in  respect  of  this  sex : — Tvvrj  ov 
7T0$a<ypia:  r\v  firj  ra  Karafirjvta  avrir]  eKKlirT] ; 1  but  facts  do  not 
support  the  doctrine  thus  laid  down. 

The  following  case  was  well-marked : — 

A.  M.  W.,  £et.  twenty-four,  single,  never  very  robust.  Dark-haired,  somewhat 
sallow  and  lean.  Father  healthy  and  active.  Mother,  a  Swiss,  under  my  care 
some  years  previously  with  Graves'  disease,  of  which  she  died.  Both  parents 
and  patient  strictly  temperate.  Paternal  aunt  crippled  with  alleged  "rheumatic 
gout."  Came  on  February  23,  1887,  with  pain  in  left  metacarpo-phalangeal  and 
phalangeal  joints  of  left  forefinger.  Had  suffered  much  during  the  winter  from 
chilblains  on  hands  and  ears,  also,  occasionally,  from  other  erythematous  eruptions. 

1  A<f>opi<TfjLoi,  t/jl^/xo.  '4ktqv,  29.     Cullen  referred  to  this,  and  denied  the  truth  of  it. 


324  GOUT   IN   WOMEN. 

Ctma.  regular.  The  feet  have  been  tender  and  weak,  and  the  right  great  toe-joint 
aching.  On  the  26th,  after  taking  some  iodide  of  potassium  and  iron,  pain  set  in 
in  right  great  toe-joint  of  tight,  bursting  character.  The  hand  was  relieved. 
Kapid  improvement  under  colchicum  and  magnesium  carbonate.  Subsequently, 
quinine  and  iodide  of  potassium  were  given,  and  occasional  doses  of  blue  and 
compound  colocynth  and  henbane  pill. 

This  was  a  case  of  acute  but  atonic  gout.  The  pulse  was  soft 
and  the  tongue  clean  and  flabby.  It  is  not  unlikely  that  the  iron 
given  at  first  helped  to  determine  the  attack. 

Tophaceous  gout  in  women  is  exceedingly  rare.  I  do  not 
remember  to  have  seen  more  than  four  or  five  well-marked  cases. 
Tophi  in  the  ears  of  women  are  also  very  seldom  met  with.  The 
following  case  was  one  of  the  worst  I  have  seen  : — 

A.  H.,  ast.  thirty-eight,  admitted  under  my  care  in  Elizabeth  Ward,  May  to 
August,  1888.  Fair-haired,  slender  woman.  Married,  and  has  a  family.  No 
serious  illnesses.  Not  exposed  to  lead  influence.  No  history  of  gout  in  her  family 
is  obtainable.  At  the  age  of  twenty  years  had  first  attack  of  gout  in  right  great 
toe-joint,  and  has  had  many  subsequent  attacks,  generally  three  in  each  year. 
Was  subject  to  "bilious  sick  headache"  for  three  years  before  onset  of  gout,  the 
attacks  having  occurred  monthly.  There  is  much  uratic  deposit  in  the  hands, 
one  mass  being  as  large  as  a  walnut,  and  some  in  the  helices  of  the  ears.  There 
has  been  some  in  the  toes,  which  has,  she  states,  been  discharged.  There  is  a 
history  of  whisky-  and  rum-drinking. 

Dr.  Haig  has  reported  this  case  in  respect  of  uric  acid  excretion 
under  the  influence  of  certain  drugs.1 

The  influence  of  the  catamenia  as  a  measure  of  systemic  depu- 
ration has,  no  doubt,  much  to  do  with  the  differences  met  with 
in  gout  in  the  two  sexes.  It  is  certainly  the  case  that  the  dis- 
order appears  in  women  soon  after  the  menopause,  and  menor- 
rhagia  has  been  noted  as  not  an  infrequent  occurrence  before  the 
cessation  of  the  menses  in  goutily  disposed  habits.  A  hemor- 
rhagic tendency  pertains  to  the  daughters  of  gouty  men  (not 
reaching  the  grade  of  haemophilia),  whence  epistaxis,  occasional 
menorrhagia,  and  hgemorrhoidal  flux.  Such  overflow,  when  not  so 
excessive  as  to  induce  debility  and  severe  anaemia,  may  prove 
depurative,  and  thus  avert  gouty  paroxysms. 

The  manifestations  of  gout  in  women  are  commonly  of  the 
incomplete,  asthenic,  or  irregular  varieties.  Women  suffer  rather 
from  goutiness  than  from  gout.  Many  of  these  cases  are  roughly 
included  in  the  category  of  "  rheumatic  gout,"  so  called,  and  are 
sometimes  mistaken  for  chronic  rheumatic  arthritis.  Many 
joints  may  be  involved.  The  hands  display  the  changes  most 
markedly. 

1  St.  Barth.  Hosp.  Reports,  vol.  xxiv.,  1888,  p.  217. 


GOUT   IN    WOMEN.  325 

As  I  have  already  remarked,  some  of  the  varieties  of  Heber- 
den's  nodes  are  the  result  of  chronic  gout  in  women.  The  digits 
are  distorted  variously,  knotty  at  the  joints,  with  axial  dis- 
placements, especially  affecting  the  terminal  phalanges,  which 
may  be  everted  or  inverted  in  respect  of  an  imaginary  mesial 
line.  The  nails  are  usually  fluted  or  coarsely  striated.  The 
whole  hand  thus  becomes  enlarged,  and  larger  gloves  are  re- 
quired. Burning  pains  occur  in  the  phalanges,  and  the  small 
crab's-eye  cysts  already  described  may  form  over  the  terminal 
nodes.      (Vide  Fig.  13,  p.  81.) 

Pains  in  the  feet  are  often  felt,  achings  and  burnings,  espe- 
cially of  the  soles,  and  this  is  apt  to  be  troublesome  at  night. 
Dietetic  indiscretions  readily  aggravate  these. 

These  signs  may  occur  in  the  third  decade,  especially  if  there 
be  strongly  marked  heredity ;  but  they  are  more  frequent  in  the 
fifth  and  sixth  decades. 

Such  women  are  sometimes  of  robust  constitution,  but  the  gene- 
ral health  may  be  feeble  in  other  cases,  and  many  anomalous  and 
wearying  pains  in  the  limbs  and  trunk  may  be  associated  with 
this  phase  of  goutiness.  Such  troubles  are  often  called  by  the 
lower  orders  "  rheumatics."  The  amount  of  real  crippling  is  small 
as  compared  with  that  induced  by  chronic  rheumatic  arthritis. 
Glycosuria  may  be  also  associated  with  this  state ;  so  may  varie- 
ties of  eczema,  vertigo,  cramps  in  the  legs,  various  dysesthesias, 
deafness,  tinnitus,  mental  irritability,  heats,  flushings,  acid  dys- 
pepsia and  hepatalgia.  All  these  troubles  are  recognized  as 
manifestations  of  goutiness  generally.1  Anti-gouty  medication 
and  regimen  mostly  relieve  them,  and  removal  to  a  dry  mild 
climate  in  winter  is  very  beneficial. 

Failing  to  find  evidence  of  uratic  deposit  or  history  of  overt 
arthritis,  the  clinical  purist  may  hesitate  to  make  a  diagnosis  of 
gout  in  such  cases.  Family  history  and  the  clinical  phenomena 
must,  however,  suffice  to  decide  the  line  of  treatment.  Pregnancy 
is  sometimes  determinant  of  more  or  less  widely  spread  subacute 
arthritis  in  women  of  gouty  heritage.  After  delivery,  the  articular 
symptoms  may  completely  subside,  but  other  incomplete  gouty 
ailments  are  apt  to  arise  from  time  to  time,  such  as  bronchitis 
with  noisy  laryngeal  cough,  teasing  eczematous  eruptions,  glyco- 
suria, joint-pains,  and  plantar  causalgia.  Any  of  these  ailments 
plainly  proclaim  the  dominant  diathetic  state,  and  as  plainly  indi- 
cate the  treatment  proper  for  it. 

1  "  The  morbid  localizations  are  nothing  more  than  manifestations  of  one  general 
dominant  tendency." — Trousseau. 


326  GOUT    IN    EARLY    LIFE. 


Gout  in  Infancy  and  Early  Life. 

W.  Gairdner  reported  the  occurrence  of  fits  of  painful  gout  in 
infants  at  the  breast,  and  believed  that  the  pain  alone  in  one  case 
was  the  cause  of  death.  He  quotes  observations  of  Morgagni  to 
the  same  effect,  ancestral  gout  forming  the  essential  factor  in  the 
history.  I  have  never  met  with  such  cases,  but  have  witnessed 
some  about  the  first  climacteric  period. 

Gout  occurring  in  young  persons  may  be  fairly  set  down  to 
hereditariness,  and,  according  to  Laycock,  is  significant  of  a  feeble 
constitution. 

The  prognosis  of  gout  is  much  more  grave  when  it  comes  out 
early  in  life  with  history  of  heredity.  For  purposes  of  life-assur- 
ance, such  cases,  if  accepted,  should  be  heavily  weighted.  The 
onset  of  gout  after  the  fourth  or  fifth  decade  of  life  is  of  much 
less  importance  in  this  respect.  Laycock  noted  that  gouty  male 
children  were  often  fond  of  meat,  while  girls  thus  impressed 
were  apt  to  loathe  it,  and  suffered  from  what  he  termed  kreatic 
nausea. 

Sir  Henry  Pitman  has  given  me  the  following  particulars  of  a 
well-marked  case  of  acute  gout  in  the  great  toe-joint,  which 
occurred  in  a  boy  at  the  age  of  eleven  years.  Heredity  was  traced 
to  a  grandfather.  There  was  present  at  the  time  of  the  attack  an 
enlarged  scrofulous  gland  in  the  neck.  The  patient  is  still  living, 
about  fifty  years  of  age,  and  has  been  subject  to  attacks  of  gout 
from  time  to  time.  At  Cambridge  he  drank,  not  immoderately, 
of  college  ale,  which  is  a  sufficiently  gout-provoking  beverage. 

Tonsillitis  (quinsy),  enlarged  tonsils,  granular  states  of  the 
pharynx,  and  catarrhal  conditions  of  the  throat  and  respiratory 
mucous  membranes  are  not  infrequent  expressions  of  gouty  in- 
heritance in  children.  Tendency  to  hepatic  congestion  with 
"  biliousness  "  and  pale  stools  are  also  thus  recognized,  and  such 
attacks  recur  from  time  to  time,  reminding  one  of  the  like 
"  growing  up  "  of  regular  gout  in  adults.  Gastro-enteric  catarrh 
may  occur,  and  loaded  states  of  the  urine.  There  is  also  tendency 
to  various  skin-disorders  and  to  herpetic  outbreaks,  as  has  been 
already  mentioned. 

In  one  case,  within  my  knowledge,  a  very  temperate  gentle- 
man had  minor  gouty  troubles  all  his  life,  but  never  had  an 
acute  attack  till  the  age  of  eighty-six,  when  he  was  on  his 
death-bed. 

In  persons  of  vigorous  constitution,  attacks  may  continue  to 


GOUT    IN   ADVANCED    LIFE.  327 

come  on  at  intervals  in  advanced  life  with  but  little  general 
disturbance  to  the  system,  and  not  calling  for  any  very  active 
treatment. 

Gout  in  Advanced  Life. 

Instances  are  not  uncommon  where  the  first  overt  attack  of 
paroxysmal  gout  has  occurred  at  or  after  the  assigned  limit  of. 
human  life.  I  have  knowledge  of  several  instances  where  the 
patient  had  reached  eighty  years  of  age  before  a  first  acute  attack 
appeared.  Scudamore  had  no  experience  of  such  a  case  after 
sixty-six  years  of  age.  Garrod  records  a  first  attack  in  a  lady 
of  ninety-one,  and  relates  the  case  of  a  Bishop  of  Durham  who 
thus  suffered  at  the  age  of  ninety,  having  been  lithotomized  when 
twelve  years  old.      He  lived  to  ninety-two. 

Although  in  these  cases  the  attack  of  frank  gout  has  been 
remarkably  delayed,  it  is  certainly  true,  for  some  of  them,  that 
many  minor  tokens  of  the  gouty  habit  had  occurred  in  previous 
years,  so  that  a  paroxysm  might  sooner  or  later  have  been  pre- 
dicted. 

In  the  aged  it  has  been  observed  that  any  unusual  shock, 
mental  or  traumatic,  sufficient  to  disturb  the  balance  of  healthy 
nutrition,  has  been  determinant  of  a  gouty  paroxysm.  Passage 
of  uratic  gravel  and  calculi  sometimes  occurs  in  elderly  gouty 
men,  with  relief  to  articular  attacks ;  and  temporary  glycosuria 
may  occasionally  replace  gouty  fits. 


Incidence  of  Gout  upon  Particular  Members  of  Families. 

It  has  been  observed  that  the  younger  children  of  gouty 
parents  are  sometimes  more  prone  to  develop  the  disease  than 
the  elder  ones.  This  is  explained  by  the  fact  that  the  parents 
are  apt  to  be  more  gouty  with  advancing  years,  and,  so,  more 
liable  to  pass  on  the  disorder  to  their  later  offspring.  The  in- 
fluence of  atavism  sometimes  only  comes  out  with  later  pro- 
creation. A  parent  with  gouty  proclivity  may  die  before  overt 
gout  appears,  who  would,  had  he  lived,  have  perhaps  manifested 
it  later  in  life. 

The  habits  of  individual  members  of  families  must,  of  course, 
be  taken  into  account  in  considering  the  incidence  of  the  disease 
on  particular  sons  or  daughters.  The  variety  and  degree  of 
goutiness,  also,  in  any  individual  member  may  depend  much  on 


328       INCIDENCE    OF    GOUT    ON    MEMBERS    OF    FAMILIES. 

the  condition  of  health  of  the  parent,  especially  of  the  father,  at 
the  time  of  procreation. 

W.  Gairdner  believed  that  some  of  the  worst  forms  of  atonic 
gout  are  probably  to  be  met  with  in  the  offspring  of  profligate  and 
debauched  fathers.  Such  men  can  but  transmit  a  frail  nervous 
system,  possessing  evil  potentiality  and  instability. 

Likeness  in  features  may  naturally  be  supposed  to  pass  on 
together  with  likeness  in  tissue-organization  and  propensity. 


F/G.  2. 
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CHAPTER  XVIII. 

PYREXIA    IN    GOUT. 

1.  Pyrexia  in  Acute  Gout. — I  have  endeavoured  to  illustrate  the 
type  of  pyretic  movement  in  acute  gout  by  a  study  of  a  number 
of  cases  which  have  occurred  in  the  Hospital  during  the  last  few 
years,  and  I  am  indebted  to  my  late  research  clerk,  Mr.  Scott, 
for  securing  the  facts  for  me  from  the  clinical  temperature  charts 
in  sixty-five  cases.  As  it  would  be  impossible  to  set  these  out 
in  full,  I  give  the  results  in  figures  and  append  a  few  charts. 
(Vide  Plate  2.)  The  temperatures  are  usually  taken  at  8  A.M. 
and  8  p.m.  These  were  all  male  cases,  the  eldest  being  sixty- 
eight,  the  youngest  twenty-seven.  The  greater  number  were 
between  forty  and  sixty  years  of  age. 

In  some  cases  I  have  had  them  taken  day  and  night  every  four 
hours.  The  pyrexia  is  best  observed  in  cases  which  occur  while 
the  patients  are  in  hospital,  no  early  record  being  attainable  in 
patients  admitted  with  acute  gout.  Such  cases  are  rarely  admitted. 
I  find  that  the  temperature  seldom  exceeds  102°  in  the  sharpest 
attacks,  if  there  is  no  complication.  A  preliminary  rise  is  com- 
monly noted  for  one,  two,  three,  or  four  days  before  a  joint  is 
actively  involved,  the  evening  temperatures  always  being  highest. 
With  onset  of  overt  symptoms  there  is  a  fairly  sharp  rise  to  ioo° 
or  1 00. 4°  in  the  evening,  with  a  remission  the  following  morning 
to  normal  or  98.8°.  On  the  second  day  there  is  an  evening  rise  to 
10 1  °  or  102.2°,  followed  by  a  morning  remission  to  99-6°,  or  even 
subnormal  as  low  as  97°.  The  evening  rise  thereafter  is  usually 
irregular,  reaching  ioo°  or  10 1°,  and  remitting  on  subsequent 
mornings  to  normal  or  a  little  below  this.  The  pyrexia  lasts  from 
two  to  seven,  eight,  or  ten  days,  and  subsides,  often,  with  a  sub- 
normal range  for  a  few  days.  In  not  a  few  cases  there  is  but 
little  pyrexia,  the  temperature  hardly  reaching  100°  even  at  night. 


330  PYREXIA   m   GOUT. 

Where  temperatures  are  frequently  taken,  the  highest  pyrexia 
is  observed  at  six  in  the  evening,  and  the  lowest  at  eight  or  ten 
o'clock  in  the  morning.  The  rise  begins  in  the  forenoon,  and  the 
fall  begins  towards  midnight,  continuing  gradually  till  8  a.m. 

In  relapses,  the  temperature  may  rise  suddenly,  with  an  evening 
exacerbation.  In  one  case  there  was  a  rise  from  normal  to  I  o  1 .2° ; 
next  morning  ioo° ;  next  evening  102.2°  ;  next  morning  ioo.6°  ; 
same  in  evening;  next  morning  98.4°;  and  thereafter  sub- 
normal. This  was  in  a  man,  set.  twenty-nine,  whose  first  attack 
occurred  eight  years  previously.  The  relapse  occurred  three 
weeks  after  he  had  been  in  hospital  for  the  former  attack. 

The  highest  temperatures  occur  in  sthenic  gout  in  young  men, 
when  there  is  plenty  of  vital  power  and  reaction  in  the  system. 
My  cases  show  that  age  has  not  much  influence  in  regulating  the 
degree  of  pyrexia  attained,  for  some  of  the  highest  records  occurred 
in  men  over  fifty.  In  the  oldest  man,  set.  sixty-eight,  100. 8° 
was  reached  on  the  fifth  night,  the  highest  point  noted.  In  a 
man  get.  sixty,  10 1°  was  noted  on  the  fourth  evening,  and  10 1.4° 
on  the  fifth  evening.  The  attack  commonly  subsides  in  two  days 
after  the  acme  is  reached,  but  may  linger  on  for  a  week.  In  a 
man  aged  fifty-four,  who  had  a  hydatid  tumour,  presumably  of  the 
liver,  an  acute  attack  began  on  May  7,  with  an  evening  rise  to 
1 02. 4°,  but  the  temperature  had  begun  to  rise  two  days  before, 
reaching  101.2°  the  previous  night.  This  attack  lasted  twelve 
days,  pyrexia  ruling  from  100. 2°  to  102. 2°  for  five  days. 

2.  Pyrexia  in  Chronic  Gout. — In  most  cases  of  chronic  gout  and 
gouty  cachexia,  there  is  no  noteworthy  type  of  temperature.  My 
cases  show  that  pyrexia  only  occurs  with  such  exacerbations  as 
practically  constitute  instances  of  acute  gout.  In  such  cases  there 
may  be  a  rise  to  ioo°  or  10 1°  at  night  for  two  or  three  nights, 
but  the  pain  and  symptoms  of  disturbance  may  last  long  after 
the  temperature  has  become  normal.  In  many  instances  there  is 
a  slight  continuous  pyrexia  while  pain  lasts  in  various  joints,  and 
this  may  persist  for  several  weeks. 

These  cases  are  commonly  intractable,  little  influenced  for  good 
by  any  drugs  or  treatment,  and  slight  exacerbations  are  frequent. 
They  are  not  seldom  mistaken  in  practice  for  cases  of  chronic 
rheumatism,  and  as  there  are  polyarthritic  pains,  the  likeness  to 
the  latter  is  more  noteworthy.  They  are  most  common  in  men 
past  middle  life,  already  broken  down  by  repeated  gouty  attacks, 
and  often  by  intemperance.  Their  pains  abate  slowly,  and  there 
is  prolonged  convalescence. 

In  noting  these  temperatures,  care  has  been  taken  to  exclude 


PYREXIA   IN   GOUT.  33  I 

all  complications  such  as  pneumonia,  adenitis  (which  occurred  in 
one  case),  and  delirium  tremens. 

The  charts  (Plate  2)  have  been  selected  from  a  large  series, 
and  exemplify  the  main  characters  of  the  pyrexia  accompanying 
acute  gouty  paroxysms  in  joints. 

Figs.  1  and  2  illustrate  a  common  type  of  febrile  movement. 
In  3,  5,  6,  7,  8,  and  9,  it  is  shown,  as  already  pointed  out,  that 
before  the  acute  features  of  an  attack  the  temperature  rises,  some- 
times one,  two,  or  even  four  days  previously.  In  9  there  was  a 
serious  complication  with  an  attack  of  delirium  tremens,  and  with 
the  unstable  condition  of  the  thermic  centre,  thus  associated,  there 
is  to  be  observed  a  higher  degree  of  pyrexia  than  is  usual. 

Where  many  joints  are  involved,  there  is  commonly  only 
moderate  pyrexia.  This  clinical  feature  aids  in  the  diagnosis  of 
these  cases  which  often  closely  simulate  acute  rheumatism,  even 
in  respect  of  severe  sweating.  In  one  case  of  this  kind  lately 
under  my  care,  in  a  man  aged  forty,  of  gouty  heritage,  who 
had  had  previous  attacks  of  gout  in  his  great-toes,  the  sweating 
was  profuse  for  some  days,  but  there  was  no  sour  rheumatic 
odour  given  off  with  it.  The  temperature  never  exceeded  ioi°, 
and  was  mostly  below  this.  There  was  much  effusion  into  the 
right  knee-joint  in  this  case,  and  severe  pain  in  the  toes,  ankles, 
and  some  of  the  digital  joints  of  the  right  hand. 

In  10,  taken  from  a  woman  with  cancer  of  the  liver,  a  very 
slight  pyretic  reaction  was  present  during  acute  attacks.  The 
influence  of  cancer  and  the  cachectic  condition  of  the  patient 
appeared  to  modify  the  thermometric  ranges.  If  any  pyrexia 
occurs  in  connection  with  cancer,  it  is  usually  slight  or  moderate. 

The  local  temperature  of  joints  involved  in  acute  gouty  attacks 
is  commonly  lower  than  that  of  the  axilla  or  mouth,  sometimes 
by  five  or  six  degrees,  although  the  part  feels  decidedly  hotter  to 
the  hand  than  unaffected  areas.  The  latter  sensation  is  therefore 
due,  on  the  principle  of  uhi  stimulus,  ibi  fluxus,  to  the  greater 
quantity  of  blood  in  the  vicinity  of  the  inflammatory  focus. 


CHAPTER  XIX. 

GOUT  IN  RELATION  TO  THE  VARIOUS  CLASSES 
AND  AVOCATIONS  OF  SOCIETY. 

I  HAVE  already  stated  my  belief  that  gout  spares  no  class  in  any 
population.  Hence,  may  be  met  rich  and  poor  man's  gout.  With- 
out paradox,  too,  it  may  be  added  that  the  rich  man  may  be  the 
subject  of  "  poor,"  that  is,  atonic  or  imperfect,  gout,  and  the 
humble  artisan  the  victim  of  severe  and  frank  gout. 

Regarding  the  disorder  as  one  primarily  due  to  dietetic  errors 
and  excess,  it  has  come  to  be  popularly  considered  as  the  appa- 
nage of  those  who  are  exposed  to  luxury. 

Its  incidence  in  greater  frequency  on  the  upper  classes  is,  doubt- 
less, thus  largely  explicable.  In  families  of  ancient  lineage,  which 
are  often  markedly  gouty,  there  has  been  an  intensifying  influence 
at  work  by  reason  of  intermarriage  amongst  individuals  similarly 
circumstanced  in  respect  of  the  good  things  of  this  world.  Mar- 
riages of  consanguinity  between  members  of  gouty  families  will 
naturally  tend  to  aggravation  of  the  habit  in  succeeding  genera- 
tions. The  ill  effects  of  these  are  seen  especially  amongst  wealthy 
members  of  the  Hebrew  race  where  they  congregate  in  large 
cities,  and  whose  families  are,  strangely  enough,  more  prone  to 
gout  and  phases  of  goutiness  than  to  tuberculosis  and  strumous 
disease. 

In  considering  the  incidence  of  gout  upon  classes,  regard  must 
be  had  to  the  influences  of  country-  and  town-life  upon  the 
individuals,  and  many  other  factors  come  into  play  in  each  of 
these.  Thus,  the  nature  of  the  occupation,  habits,  diet,  the  char- 
acters of  the  soil  and  water,  must  all  be  taken  into  account. 

A  country  squire,  whose  time  is  divided  between  his  duties  and 
varieties  of  sport,  is  commonly  regarded  as  a  likely  subject  of 
classical  gout,  because,  hypothetically,  he  comes  of  long  lineage, 
his  ancestors  lived  freely,  and  he  himself  tends  to  follow  in  many 


INCIDENCE  OF    GOUT    ON    PROFESSIONAL    MEN.  333 

of  their  steps.  He  may  nowadays  do  more  than  this,  and  take 
an  active  part  in  the  strain  of  town-life  for  a  considerable  part  of 
the  year.  It  would  be  hard  to  determine  the  share  taken  by  each 
of  the  dual  parts  of  such  a  man's  life  in  generating  or  evoking 
gout. 

Political  life  is  notoriously  conducive  to  gout.  The  tension 
and  strife  involved  by  it,  together  with  the  high  living  which 
hard  thinking  is  apt  to  induce,  and  the  insufficient  bodily  exercise 
and  sleep  thus  entailed,  are  all  provocative  of  this  disorder. 

When  to  these  are  added  the  responsibility  and  anxiety  attach- 
ing to  high  political  office,  hardly  a  factor  is  wanting  to  evoke 
gout  in  the  holders  of  it. 

It  is  difficult  to  affirm  dogmatically  as  to  the  incidence  of  gout 
in  the  several  learned  professions.  It  is  certain  that  there  is  now 
less  frank  gout  amongst  the  members  of  all  of  these  than  was 
prevalent  half  a  century  ago. 

Respecting  the  Clergy,  inasmuch  as  there  is  little  or  no  gout 
in  Scotland  and  Ireland,  the  question  is  practically  limited  to 
that  profession  in  England,  and  amongst  these  it  may  now  be 
declared  that  the  disease  in  its  frank  form  is  not  often  met  with. 
The  manner  of  life  of  the  modern  parish  priest  is  one  little  likely 
to  rouse  into  activity  even  a  lurking  taint  of  gout,  and  perhaps 
sufficient  evidence  of  the  immunity  of  the  English  clergy  from 
gouty  cachexia  is  afforded  by  the  highly  satisfactory  life-statistics 
relating  to  that  profession.  -  These  demonstrate  that  activity  of 
body  and  mind,  with  the  regularity,  for  the  most  part,  of  their 
duties,  is  conducive  to  a  long  lease  of  health.  The  abstention 
from  alcoholic  beverages  now  so  commonly  practised  by  the  clergy 
will  doubtless  avert  much  frank  gout ;  but,  where  gouty  heritage 
exists,  incomplete  phases  of  it  will  not  improbably  be  manifested 
in  the  descendants  for  several  generations. 

The  incidence  of  gout  on  Lawyers  is  considerable,  and  greater 
by  far  than  on  the  Clergy.  The  causes  which  commonly  determine 
the  disorder  come  into  full  operation  in  practising  lawyers.  Brain- 
work,  pressure  of  business,  sedentary  life  in  a  vitiated  atmosphere, 
the  high-living  that  mental  exercise  necessitates  in  men  of  affairs, 
all  tend  to  induce  a  gouty  state.  Those  who  succeed  in  any 
profession  which  entails  brain-work,  together  with  the  strain  of 
practice,  are  naturally  men  of  originally  robust  constitution,  who 
have  led  in  their  earlier  years  active  out-door  lives  ;  and  when,  by 
reason  of  their  success,  they  are  compelled  to  alter  their  habits, 
and  live  in  confined  air  in  large  cities,  they  become  particularly 
prone  to  develop,  or  to  acquire,  gout. 


334 


GOUT   IN    RELATION   TO    SOCIETY. 


These  conditions  especially  prevail  in  the  Medical  profession, 
in  which,  however,  gout  figures  to  a  less  extent  than  amongst 
Lawyers.  Medical  practice  commonly  entails  a  good  deal  of  out- 
door life,  and  greater  activity  of  body  than  that  of  Law. 

I  am  indebted  to  my  friend  Deputy  Inspector-General  William 
H.  Lloyd,  of  the  Medical  Department  of  the  Admiralty,  for  the 
subjoined  statistics  relating  to  the  occurrence  of  gout  for  the  last 
twenty  years  amongst  seamen  and  marines  serving  afloat  in  the 
Eoyal  Navy.  In  respect  of  this  return,  it  must  be  noted  that 
it  includes  observations  made  by  many  naval  surgeons  in  various 
parts  of  the  world.  Dr.  Lloyd  remarks  that  the  force  on  which 
these  ratios  are  calculated  has  been,  on  an  average,  about  45,000 
yearly,  and  that  the  number  of  cases  is  not  likely  to  be  over- 
stated. Practically,  the  ages  were  from  15I  to  45  years,  only 
about  3  per  cent  of  the  force  being  above  45  years  old.  The 
incidence  of  the  disease  in  the  various  ages  cannot  be  given. 


Statement  showing  the  Number  of  Cases  of  Gout,  ivith  the  Ratio  per  1000  of  Force, 
n  the  Royal  Navy  for  the  years  1868-1887. 


Year. 

Cases. 

Year. 

Cases. 

No. 

Ratio  per  1000. 

No. 

Ratio  per  1000. 

1868 
1869 
1S70 
1871 
1S72 
1873 
1874 
1875 
1876 

1877 

98 

S7 
82 

105 
94 
93 

102 

99 

118 

98 

1.9 

1-7 

i-7 

2.2 

2. 

2. 

2.2 

2.2 

2.6 

2.1 

1878 
1879 
1880 
1881 
1882 
1883 
1884 
1885 
1886 
1887 

102 
79 
89 
62 
80 

IOO 
86 
79 
78 
90 

2.1 

1-7 
1.9 

1-3 

1.8 

2-3 

2. 
1.6 
1.6 
1.8 

For  the  following  statistical  Table,  relating  to  the  incidence  of 
gout  on  British  troops  serving  in  all  parts  of  the  world,  I  am 
under  obligation  to  my  friend  Surgeon-Major  William  Nash,  who 
has  obtained  permission  for  its  publication  from  the  Director- 
General  of  the  Army  Medical  Department.  The  Table  indicates 
the  marked  infrequency  of  gout  amongst  soldiers  serving  with  the 
colours.  The  admissions  were  more  numerous  in  the  last  three 
years  than  they  were  twenty-five  years  since,  but  were  very  few  in 
either  period. 


GOUT  IN  THE  NAVY  AND  IN  THE  ARMY. 


335 


Return  showing  the  Average  Annual  Strength,' and  the  Number  of  Cases  of  Gout 
admitted  into  Hospital,  Deaths,  and  Average  Number  constantly  Sick,  among  II<  r 
Majesty's  British  Troops  during  the  years  1862- 1864  and  1885- 1887,  vnth  the 
ratio  per  1 000  of  strength. 


Years. 

Average 
Annual 

Strength. 

Admissions 

into 

Hospital. 

Deaths. 

Average 
Number 

constantly 
Sick. 

Ratio  per  1000. 

Admissions 

into 

Hospital. 

Deatbs. 

Average 

Number 

constantly 

Sick. 

1862 
1863 
1864 

197,550 
199,007 
192,147 

18 
46 

No  infor- 
mation. 

.09 
.20 
.24 

... 

Total 

588,704 

I05 

.18 

... 

1885 
1886 
1887 

177,928 
188,739 
193,975 

78 

59 
70 

4.07 
3-" 
3-29 

•44 
•31 
•36 

... 

.02 
.02 
.02 

Total 

560,642 

207 

10.47 

•37 

.02 

Sailors  are  practically  free  from  gout  so  long  as  they  actively 
follow  their  calling,  and  the  same  may  be  affirmed  of  soldiers. 
In  both  these  vocations,  especially  in  the  army,  the  men  are 
young,  and,  therefore,  not  of  an  age  to  manifest  the  disorder. 
Their  active  lives  in  the  open  air  tend,  further,  to  check  its  deve- 
lopment. Retired  naval  and  military  men  are  not  infrequently 
the  subjects  of  gout. 

The  following  cases  were  reported  for  me  by  Dr.  Sidney 
Davies : — 


I. — Gout  in  a  Sailor. — Alfred  B.,  set.  63,  came  to  the  out-patient  department  of 
St.  Bartholomew's  Hospital  on  May  8th,  suffering  from  a  severe  attack  of  gout  in 
several  of  his  joints.  He  had  been  for  forty-five  years  at  sea,  and  was  a  master- 
mariner  when  he  left  his  ship,  having  become  incapacitated  by  the  gout.  Being, 
in  consequence,  reduced  in  circumstances,  he  went  into  the  Union  infirmary  for  a 
time.  No  history  whatever  was  obtainable  as  to  gout  or  rheumatism  in  any  of  his 
ancestors  or  relations.  One  brother,  older,  has  never  suffered.  He  used  to  drink 
bottled  beer  and  Hollands  gin  in  moderation  when  at  sea.  His  first  attack  of  gout 
occurred  fourteen  years  ago,  while  he  was  sailing  on  the  coast  of  Africa,  within 
four  degrees  of  the  equator.  The  pain  seized  him  about  midnight  in  the  great  toe. 
Two  days  after  it  went  to  the  ankle.  After  the  attack  had  lasted  a  few  days,  it 
left  him  for  a  space  of  two  years.  Subsequently,  the  attacks  came  on  about  every 
year,  and,  latterly,  three  or  four  times  a  year.  The  hands  were  first  affected  sis 
years  ago,  the  elbows  and  knees  four  or  five  years  ago,  and  the  shoulders  and  hips 
since  that  time. 

When  he  presented  himself,  the  patient  had  a  pallid  anaemic  appearance.    His 


336  GOUT    IN    EELATION   TO    SOCIETY. 

hair  was  grey,  his  teeth  strong,  and  well- enamelled.  There  were  no  tophi  in  the 
ears,  or  anywhere  else.  The  mucous  membranes  were  pale,  uvula  large  ;  tongue 
pale,  coated  with  a  thin  yellow  fur.  Hands  much  deformed  ;  carpus  deflected 
to  the  ulnar  side.  Fingers  of  "  parsnip  "  type.  Extremities  of  the  ulnse  much 
enlarged.  Knuckles  everywhere  enlarged.  Eight  hand  oedematous.  He  was  not 
troubled  with  cramp  in  the  legs.  There  was  visible  pulsation  in  the  brachial 
arteries.  The  heart-sounds  were  clear.  There  was  thickening  of  the  bursa  over 
the  right  olecranon.  Urine  1015,  acid,  contained  a  trace  of  albumen,  but  no  sugar. 
The  patient  has  had  no  previous  illness  but  "  fever."  He  stated  that  he  slept 
well,  but  had  to  get  up  three  or  four  times  in  the  night  to  make  water.  He  was 
ordered  the  following  prescription: — Pot.  iod.,  gr.iij. ;  syr.  ferri  iod.,  f3ss. ;  tr. 
nuc.  vom.,  itlx.  ;  aquas,  fgj.  ter  die  sum.,  and  lin.  sinapis  co.  to  apply  to  the  affected 
joints. 

When  he  presented  himself  at  the  Hospital,  he  had  been  in  continual  suffering 
for  six  months. 

On  May  28th  he  said  he  felt  much  better.  The  medicine  was  discontinued, 
and  he  was  ordered  lin.  saponis  co.,  f giv.,  tr.  iodi,  f  gss.,  to  be,  mixed  and  applied 
to  the  joints  instead  of  lin.  sinapis  co. 

On  June  4th  he  was  better.  Ankylosis  existed  in  many  of  the  phalangeal  joints 
of  both  hands ;  only  the  forefingers  and  thumbs  could  be  opposed,  so  that  the 
grasp  was  very  imperfect. 

August  3rd. — Continues  free  from  pain. 

II. — Gout  in  a  Sailor. — Peter  W.,  set.  seventy-three,  came  to  the  Hospital  on 
April  6,  to  seek  relief  from  an  attack  of  gout,  chiefly  in  the  left  hand.  He  had 
lived  at  Padstow  and  at  Plymouth,  and  was  formerly  a  sailor.  He  was  married, 
had  six  children,  and  the  eldest  son  was  living,  aged  fifty-three,  was  formerly  a 
sailor,  and  suffered  from  gout. 

The  patient  was  a  man  of  healthy  appearance,  his  head  was  bald  and  shiny,  he 
had  no  arcus  senilis,  and  was  nearly  edentulous,  the  teeth  which  remained  were 
yellowish  ;  eyes  glistening ;  the  nails  were  striated.  There  was  a  well-marked 
tophus  on  the  left  ear,  and  a  doubtful  one  on  the  right.  The  uvula  was  long  and 
glossy,  the  skin  of  his  hands  smooth  and  shining. 

The  first  attack  of  gout  seized  the  left  great  toe-joint  eighteen  years  ago. 
On  the  occasion  of  the  second  attack  his  left  wrist,  instep,  and  right  middle 
finger  were  involved  in  the  disease.  The  last  joint  of  the  right  middle  ringer  was 
much  enlarged.  The  fingers  were  straight.  The  bursa  over  the  right  olecranon 
was  full  of,  presumably,  uratic  deposit. 

The  patient  did  not  suffer  from  cramps,  nor  from  headaches.  His  urine  was 
acid,  sp.  gr.  1024,  and  contained  a  trace  of  albumen. 

Three  years  ago  he  began  to  have  attacks  of  "  deadness  "  at  the  end  of  the  ring- 
finger,  passing  to  the  other  fingers  and  to  the  wrist,  accompanied  by  burning 
pains,  alleged  to  be  constant.  He  was  rendered  miserable  by  them,  and  the  dis- 
comfort kept  him  awake  at  night.  The  heart-sounds  were  clear.  The  arteries 
had  the  hardness  of  senility. 

Merchants  and  men  of  business  are  certainly  prone  to  gout,  the 
more  so  if  they  take  insufficient  exercise,  and  are  exposed  to  the 
responsibilities  and  anxieties  inseparable  from  large  monetary 
transactions  and  precarious  speculations.  It  is,  doubtless,  in  re- 
spect of  the  strain  and  excitement  attendant  on  the  latter  that 
stockbrokers  are  frequently  sufferers. 

Farmers,  in  spite  of  their  wholesome  calling,  are  as  a  class 
somewhat  prone  to  gout;  but  in  their  case,  as  in  that  of  others, 


INCIDENCE  OF  GOUT  UPON  ARTISANS  AND  LABOURERS.      2>37 

a  well-marked  ratio  is  found  to  exist  between  the  occurrence  and 
frequency  of  the  disease,  and  periods  of  prosperity  or  the  reverse. 

Artisans  suffer  more  than  labourers.  The  particular  occupation 
followed  has  much  to  do  with  the  incidence  of  the  disease  in  these 
classes,  as  has  also  the  important  matter  of  habits  in  respect  of 
strong  liquors. 

Workers  in  lead  and  painters  stand  apart  from  all  others  in 
their  special  proclivity  to  become  gouty. 

In  all  the  instances  just  referred  to,  my  remarks  apply,  of 
course,  to  the  class  as  a  whole.  In  every  case,  regard  must  be 
had  to  the  influence  of  heredity,  and  to  the  individual  tendencies 
and  habits. 


CHAPTER  XX. 

GEOGRAPHICAL  DISTRIBUTION  OF,  AND  INFLUENCE 
OF  CLIMATE,  SOIL,  WATER,  AND  SEASONS  ON, 
GOUT. 

This  subject  has  received  a  good  deal  of  attention.  The  field  of 
experience  is  naturally  much  enlarged  at  the  present  time,  when 
locomotion  is  rapid  and  easily  accomplished. 

I  can  hardly  doubt  that  errors  have  crept  into  some  of  the 
accounts  available  for  a  study  of  the  geographical  distribution 
of  gout,  so  that  many  forms  of  arthritis  have  been  improperly 
reckoned  as  gout  which  have  no  claim  to  be  so  regarded. 

For  many  years  past  I  have  sought  information  from  practi- 
tioners coming  from  various  parts  of  the  world  respecting  their 
experience  of  gout,  and  in  most  instances  there  has  been  little  or 
none  forthcoming,  save  where  Europeans  have  formed  part  of  the 
community,  and  some  amongst  these  have  either  carried  hereditary 
taint  with  them,  or  have  led  such  lives  as  favour  the  onset  of 
gout. 

There  can,  I  believe,  be  no  doubt  that  there  is  more  gout  in 
the  British  Isles  than  in  any  other  part  of  the  world,  and  the 
greater  number  of  examples  are  to  be  met  with  in  England. 
The  disease  is  chiefly  spread  over  the  temperate  zone.  During 
extensive  travels  in  many  parts  of  the  world,  I  have  been  on  the 
outlook  for  gout,  and  am  compelled  to  affirm  that  I  have  seen 
very  little  out  of  England.  I  believe  that  the  next  largest  field 
is  presented  by  France,  where,  however,  the  upper  classes  present 
the  majority  of  cases.  There  would  appear  to  be  little  gout  in 
Germany,  Austria,  and  Italy.  In  Holland  there  is  practically  no 
gout,  and  but  little  is  met  with  in  Belgium  or  Spain.  In  Scan- 
dinavia the  populations  are  free  from  gout,  and  the  same  is  the 
case  in  Russia.  Yet,  in  the  capitals  and  large  cities  of  all  these 
countries  cases  of  gout  may  be  met  with,  chiefly  amongst  the  well- 


GOUT  IN  SCOTLAND,  IRELAND,  GERMANY,  AND  RUSSIA.    239 

to-do  or  luxuriously  living  of  the  community.  Some  cities  show 
greater  preponderance  than  others.  Thus,  Hamburg  and  Bremen 
furnish  more  cases,  probably,  than  Berlin.  Communities  of  rich 
merchants,  including  many  Jews,  are  likely  to  be  centres  of  gouty 
disease.1 

The  peculiarity  of  the  greater  frequency  in  (geographical)  Eng- 
land is  the  occurrence  of  the  disease  amongst  the  lower  orders, 
especially  the  artisans.  This  is  not  the  case  in  any  other  country. 
The  greatest  prevalence,  too,  is  certainly  in  London.  Some  of  the 
larger  cities  and  towns  in  England  furnish  cases  of  gout  amongst 
the  luxurious  and  well-fed  of  the  population,  but  very  little  gout 
is  met  with  amongst  the  labouring  classes.  There  is  less  gout  in 
the  North  than  in  the  South  of  England. 

In  Scotland  and  Ireland  gout  is  practically  confined  to  the 
limited  class  of  luxurious  livers.  Glasgow,  though  a  busy  and 
wealthy  commercial  centre,  furnishes  but  rarely  cases  of  gout  in 
its  upper  classes.  The  fact  is  that,  with  the  "  high  thinking  and 
plain  living "  of  Caledonia,  there  is  practically  but  little  beer, 
and  much  less  wine,  consumed  than  amongst  similar  classes  in 
England,  whisky  taking  the  place  of  both  to  a  large  extent. 

Cases  of  gout  are  hardly  ever  seen  in  the  Scottish  and  Irish 
hospitals,  and  are  rare  in  the  northern  parts  of  England.  Such 
cases  as  occur  there  are  commonly  in  the  persons  of  over-fed  and 
bibulous  men-servants. 

It  is  alleged  that  fewer  gouty  ailments  are  met  with  in  the 
area  of  the  Moselle  than  in  that  of  the  Rhine,  and  this  is  attri- 
buted to  the  respective  qualities  of  the  wine  produced  in  each 
area,  the  Rhenish  wines  being  more  acid. 

It  has,  however,  long  been  shown  that  it  is  a  fallacy  to  connect 
directly  the  occurrence  of  gout  in  any  district  with  the  dietetic 
and  drinking  habits,  or  with  the  special  liquors  consumed  in  that 
district.  Yet,  such  habits,  and  the  peculiarities  of  the  drinks 
taken,  must  be  regarded  as  factors  in  the  onset  and  evolution  of 
gout  anywhere.  These  are  not,  however,  the  sole  factors  in  in- 
ducing the  disease. 

In  Russia,  save  in  the  capitals,  little  is  known  of  gout.  In 
Greece,  Turkey,  and  the  Levant,  generally  speaking,  there  is  no 
gout.      Strict  Mahometans  are  no  subjects  for  the  disease,  but 

1  To  explain  the  occurrence  of  gout  in  Italy  and  Greece  in  the  days  of  their  early 
greatness,  of  which  there  is  trustworthy  record,  we  must  believe  that  the  habits  of 
the  people  in  respect  of  indolence,  luxury,  and  diet  were  such  as  to  induce  the  disease, 
notwithstanding  the  good  climate  they  enjoyed.  With  change  of  habits  the  disease 
has  disappeared  from  the  present  populations  of  these  countries. 


340  GEOGRAPHICAL   DISTRIBUTION,    ETC. 

where  the  habits  of  the  "  infidel"  are  followed  by  some  of  them, 
gout  is  found  to  supervene.  The  same  is  the  case  in  India. 
Only  such  natives  as  indulge  in  animal  food  and  European  liquors 
are  the  victims  of  gout.  Temperate  Europeans  may  fairly  expect 
to  escape  gout  anywhere  in  the  tropics,  but  there  is  a  good  deal 
of  gout  in  India.  Twenty-three  years'  experience  amongst  the 
European  employ  is  of  several  large  Indian  Railway  Companies  has 
convinced  me  on  this  point.  Good  living,  brandy  and  beer  in 
inordinate  quantities,  with  limited  amount  of  exercise,  together 
with  anxiety  and  head-work,  would  appear  to  be  the  inducing 
factors.  Similar  experiences  hold  good  for  Europeans  in  Ceylon 
and  China.  Hirsch,  however,  mentions  the  occurrence  of  gout 
amongst  the  indigenous  population  of  Amoy.  New  Zealand,  in 
common  with  most  British  colonies,  appears  to  be  free  from  gout. 

There  is  no  record  of  the  disease  anywhere  on  the  African 
continent,  nor  is  it  known  in  any  of  the  adjacent  islands,  in- 
cluding Madeira  and  the  Canaries.  Europeans  may  develop  gout 
anywhere,  either  from  hereditary  tendency  or  such  habits  as  lead 
up  to  the  disease  ;  and  hence  cases  are  met  with  occasionally  in 
persons  who  have  resided  in  the  tropics  or  in  colonies  where  the 
disorder  is  unknown  among  the  native  races  or  the  mass  of  colo- 
nists who  own  no  gouty  heritage. 

In  the  United  States  of  America  gout  is  practically  unknown. 
A  few  cases  are  met  with  in  the  large  cities,  but,  according  to 
Dr.  Da  Costa,  of  Philadelphia,1  the  disease  has  not  yet  developed 
amongst  the  increasing  population.  Cases  of  lithiasis  are  met 
with,  he  tells  me,  which  are  regarded  as  early  indications  of  the 
disorder.  Hence,  I  cannot  agree  with  Hirsch's  statement  to  the 
effect  that  gout  would  appear  to  be  as  common  in  the  large  and 
populous  cities  of  the  New  World  as  it  is  under  the  same  circum- 
stances in  those  of  the  Old.2 

The  ancestry,  diet,  and  habits  of  the  citizens  of  the  United 
States  for  the  most  part  are  such  as  will  long  prevent  the  onset 
of  gout  in  that  country.  The  immigration  of  Irish,  Scottish, 
Scandinavian,  and  German  people  into  that  country  peoples  it 
mainly  with  a  stock  void  of  gouty  heritage.  The  good  climate 
and  the  active  open-air  lives  of  the  people  will  tend  to  avert 
goutiness.  But  little  wine  is  used,  the  beer  is  light,  and  much 
water  and  weak  tea  are  taken.  The  alcohol  chiefly  used,  or 
abused,  is  rye-whisky. 

In  Canada  the  same  conditions  prevail. 

1  The  Nervous  Symptoms  of  Lithsemia,  Amer.  Journ.  Med.  Sciences,  October 
1881.  2  Op.  cit.t  vol.  ii.  p.  657. 


GOUT    IN    THE   COLONIES.       INFLUENCE   OF    SOIL.        34 1 

With  respect  to  colonists,  it  must  be  borne  in  mind  that  thev 
begin  their  new  life  at  an  early  age,  when  gout  is  little  likely  to 
supervene,  and  the  frugal  and  active  lives  led  by  the  majority  of 
those  who  succeed  and  live  their  full  term  naturally  prevent  the 
onset  of  the  disorder ;  and  to  these  the  words  of  Rousseau  may 
be  fairly  applied,  "Temperance  and  labour  are  the  best  physi- 
cians of  man." 

In  Australia  gout  is  practically  unknown,  except  amongst 
immigrants  already  affected.  It  is  noteworthy  that  the  colo- 
nists there  are  large  meat-eaters,  and  in  the  towns  take  beer 
freely.      They  also  consume  much  tea. 

Nothing  is  known  of  gout  in  Central  America  or  California. 
In  the  West  Indies  it  is  practically  unknown.  The  only  case 
I  have  met  with  was  in  a  gentleman  from  St.  Kitts,  who  led 
a  temperate  life,  but  had  suffered  severely  from  lead-impregna- 
tion, owing  to  improper  water-storage.  He  had  severe  gout, 
with  tophi  in  his  ears,  and  chronic  interstitial  nephritis. 

Little  is  known  of  gout  in  South  America.  Hirsch  directs 
attention  to  Dr.  Dundas's  observations  on  the  immunity  from 
gout  enjoyed  in  Brazil,  which  the  latter  deemed  remarkable, 
inasmuch  as  the  prevalent  habits  of  the  higher  classes  and  well- 
to-do  foreigners  were  such  as  to  induce  the  disorder.  Indolent 
lives  are  led  and  much  animal  food  is  taken,  but  not  much  wine. 
It  is  probable  that  not  many  Englishmen  are  included  amongst 
the  foreigners,  and  of  these,  it  may  be  assumed,  that  they  proceed 
early  in  life  to  that  country,  and  stay  no  longer  than  they  are 
compelled  to  do. 

With  respect  to  tropical  residence  and  its  influence  generally 
on  the  onset  and  course  of  gout,  it  must  be  borne  in  mind  that 
the  skin  is  kept  in  very  free  action,  that  much  diluent  liquid 
is  taken,  and  that  sun-influence  is  everywhere  a  potent  factor 
in  checking  gouty  processes.  Cases  of  confirmed  gout  are  not 
favourably  influenced  by  extreme  heat  or  by  tropical  residence, 
which  is  unduly  enervating. 

Cold  and  dry  climates  appear  to  confer  immunity  from  gout, 
and  no  less  from  rheumatic  disease  in  all  its  varieties. 

The  warmer  and  more  moist  climates  favour  the  latter,  as  is 
shown  by  the  frequency  of  chronic  rheumatic  arthritis  in  Ireland 
and  the  western  portions  of  Scotland. 

Influence  of  Soil. — Inasmuch  as  all  arthritically  disposed  per- 
sons are  very  "  barometric  "  {Trousseau l)  and  sensitive  to  damp 
and  "  shifty  climate,"  it  is  of  importance  to  have  regard  to  the 
1  A  gouty  patient  once  told  me  his  joints  were  "  barometers." 


342  GEOGRAPHICAL   DISTRIBUTION,    ETC. 

nature  of  the  soil  and  other  telluric  influences  to  which  gouty- 
persons  may  be  submitted.  They  certainly  do  best  on  dry,  gra- 
velly soil,  and  do  less  well  on  water-logged  or  clay  strata.  Chalky 
soils  are  favourable,  provided  that  hard  water  be  not  drunk. 
Sandy  soils  are  apt  to  be  somewhat  cold  and  damp,  but  sandy 
hills  with  soft  water  are  on  the  whole  not  unfavourable.  Dry 
sites  on  hilly  slopes  sheltered  from  the  north  and  east,  with  a 
southern  aspect,  are  the  best  for  the  gouty.  My  experience  fully 
confirms  the  opinion  of  Laycock  that  arthritically  disposed  per- 
sons are  favoured  by  an  inland  and  hilly  residence,  and  respond 
less  to  the  influences  of  marine  climate,  even  when  not  injuriously 
affected  by  it.1 

Such  persons  as  become  "  bilious  "  and  uncomfortable  at  the  sea- 
side are  commonly  goutily  disposed.  An  inland  residence  that  is 
at  once  high  and  dry  usually  suits  this  class  of  sufferers  better. 
East  winds  are  generally  noxious  to,  and  ill-borne  by,  gouty  per- 
sons. Extreme  heat  is  also  very  trying  for  them,2  and  they  enjoy 
most  comfort  in  temperate,  dry,  and  equable  climates.  Baro- 
metric extremes  are  equally  unfavourable,  and  the  condition  of 
atmosphere  during  thunderstorms  is  especially  disagreeable,  and 
apt  to  induce  in  the  gouty,  more  than  in  other  persons,  headache 
and  depression. 

Influence  of  Water. — The  gouty  are  very  dependent  on  the 
nature  of  their  water-supply.  Waters  much  impregnated  with 
lime  or  with  iron  are  distinctly  unsuitable  or  apt  to  provoke  gout. 
Sulphate  of  lime  in  water  is  especially  noxious  to  the  gouty.3 
Both  calcic  and  ferruginous  salts  tend  to  check  elimination  of  uric 
acid,  arid  so  are  badly  borne  by  the  gouty. 

A  question  arises  as  to  the  influence  of  climatic  and  geogra- 
phical influence  on  the  outcome  and  development  of  gout.  It 
appears  to  be  certain  that  the  conditions  of  life  in  tropical  and 
subtropical  climates  tend  to  check  the  onset  of  gout  even  when 
gouty  heritage  is  a  factor.  The  causes  at  work  here  probably 
relate  to  the  free  action  of  the  skin,  less  animalized  diet,  more 
simple  and  abundant  diluent  drinks,  and  the  generous  influence 
of  the  sun. 

1  This  point  is  well-discussed  by  Dr.  Robertson,  of  Buxton,  in  his  book  on  "Gout," 
published  in  London,  1844,  p.  33.  He  is  of  opinion  that  continual  residence  at  the 
seaside  aggravates  the  gouty  habit. 

2  Scudamore  noted  the  bad  effects  on  the  gouty  of  the  long-continued  heat  of  the 
summer  of  18 18. 

3  Hence,  the  special  harmfulness  of  a  cheap  and  factitious  wine,  "  plastered  "  with 
gypsum,  called  "  sherry." 


INFLUENCE  OF  THE  SEASONS.  343 

In  colder  but  bright  climates  void  of  moisture,  the  prevailing 
conditions  necessitate  active  muscular  exercise  and  free  aeration 
with  oxydation,  abundant  nitrogenous  food,  with  equally  abundant 
ingestion  of  hydrocarbons,  being,  thus,  readily  disposed  of. 

Under  the  influence  of  these  causes  persons  with  gouty  heri- 
tage may,  even  if  strongly  impressed  thereby,  entirely  fail  to 
develop  the  disease,  or  do  so  only  in  mild  or  incomplete  forms. 
Dr.  Robertson  thinks  there  is  good  reason  to  believe  that  the 
stimulating  air  of  the  sea-coast  diminishes  the  development  of  a 
gouty  habit,  though  intensifying  it  when  established. 

Seasons. — It  is  commonly  believed  that  gout  is  apt  to  occur 
with  greatest  frequency  in  the  spring  and  autumn.1  This  appears 
to  be  the  case  in  respect  of  attacks  of  frank  gout,  yet  there 
are  so  many  exceptions  that  it  is  not  possible  to  be  dogma- 
tic on  this  point.  It  is  certain  that  paroxysms  occur  at  all 
times  of  the  year,  and  any  frequency  observable  in  spring  and 
autumn  is  probably  attributable  to  the  climatic  peculiarities 
prevalent  at  those  seasons.2  Warm,  genial,  and  sunny  weather 
best  suits  all  subjects  of  gout,  provided  the  temperature  is  not 
excessive  and  exhausting.  East  winds  and  "shifty"  weather 
are  ill-borne.  Hence,  the  violent  changes  of  spring,  and  the 
loss  of  sun-influence  together  with  the  damp  mists  of  autumn, 
are  likely  to  check  the  action  of  the  skin,  and  throw  burdens  on 
internal  organs  which  are  conducive  to  the  generation  of  gout. 

The  same  views  prevail  in  regard  to  many  skin-disorders,  and 
probably  own  a  similar  explanation.  A  sunless  or  wet  summer 
may  prove  as  gout-provoking  as  an  ordinary  spring  or  autumn. 
A  cold  and  bright  winter,  if  there  be  little  rain  or  snow,  may 
prove  exhilarating  and  little  harmful  to  the  gouty.  The  fact  is 
that  equability  in  all  surroundings  is  best  for  such  patients,  that 
all  sudden  changes  are  harmful,  and  that  the  highest  standard 
of  health  attainable  by  them  is  only  secured  by  care  and  watch- 
fulness, de  die  in  diem,  as  to  habits  of  exercise,  food,  and  clothing. 

This  is  especially  true  for  subjects  of  the  gouty  cachexia,  and 
is  naturally  of  less  importance  in  younger  and  robust  subjects, 

1  Gout  follows  the  laws  of  other  nervous  diseases  in  respect  of  its  frequency  and 
intensity  at  certain  seasons  of  the  year.  So  does  rheumatism.  Thus,  the  curve  of 
intensity  begins  in  February,  rises  during  March  and  April,  and  falls  at  the  end 
of  that  month,  disappearing  in  summer  and  autumn,  reappearing  in  December. 
Delirium  tremens  follows  the  law  of  dietetic  ailments,  and  its  curve  rises  in  the 
summer  solstice.  Were  gout  entirely  a  dietetic  disease,  it  should  follow  the  laws 
of  such  ailments.  Thus,  winter  and  spring  are  the  worst  seasons  for  the  goutily 
disposed,  and  a  great  physiological  law  influences  gout  together  with  other  nervous 
disorders. 

2  "  Towards  rain  and  frost  gout  appears." — Lord  Verulam,  Nat.  Hist,  Cent.  ix.  p.  8. 


344  GEOGRAPHICAL   DISTRIBUTION,    ETC. 

who    can    better   withstand    vicissitudes,    both    of   climate    and 


season.1 


As  the  seasons  in  our  country  are  notoriously  uncertain  in 
character,  we  must  follow  the  advice  of  Sydenham,  and  note  the 
constitution  of  each  as  it  comes  round.  With  modern  advances 
in  meteorology,  this  becomes  a  more  exact  and  fruitful  study 
than  was  formerly  the  case. 

The  influences  of  British  winter  climate  on  the  production  of 
gouty  states  have  not  merely  to  do  with  cold  and  negation  of 
sun-influence.  Dampness  of  atmosphere  and  darkness  are  each 
provocative  by  their  directly  depressing  qualities.  In  the  absence 
of  light  and  genial  influences  externally,  a  suitable  amount  of  exer- 
cise and  aeration  is  apt  to  be  neglected,  and  pleasures  of  mind 
and  body  are  consequently  sought  indoors.  Hence,  over-action  of 
the  former,  and  under-action  of  the  latter.  Social  joys  are  sought 
to  replace  what  cannot  be  found  out  of  doors,  and  over-indulgence 
in  food  and  stimulants  is  too  commonly  the  set-off  to  the  whole- 
some influences  which  are  often  hard  to  find  out  of  doors.  Small 
wonder,  then,  that  gouty  tendency  is  aggravated  or  the  habit 
directly  induced.  Hence,  the  value  of  some  outdoor  pursuits  or 
bodily  recreation,  when  such  can  be  obtained.  These  are,  unfortu- 
nately, often  far  to  seek  in  winter  in  large  cities. 

Attacks  of  gout  are  believed  to  be  infrequent  at  sea.  The 
disease  is  extremely  rare  amongst  sailors,  but  I  have  known 
severe  attacks  to  occur  in  gouty  subjects  even  in  tropical  waters. 
Insufficient  exercise  and  over-eating,  with,  possibly,  too  free 
indulgence  in  alcoholic  liquors,  afford  sufficient  explanation  of 
such  cases.  Constipation  of  the  bowels,  common  at  sea,  is  a  pre- 
disposing cause.  Sudden  changes  from  the  tropics  into  colder 
areas  are  also  intelligible  causes  for  attacks. 

1  Laycock  taught  in  his  lectures  that  winter  was  as  dangerous  to  the  gouty  as 
to  the  tubercular. 


CHAPTER  XXI. 

TREATMENT  OP  THE  SEVERAL  VARIETIES  OP  GOUT, 
MEDICINAL,  REGIMINAL,  AND  PREVENTIVE. 

The  literature  and  lore  of  the  therapeutics  of  gout  and  of  gouty 
states  are,  like  that  relating  to  the  nature  and  phases  of  the  disease 
itself,  of  enormous  extent.  In  discussing  them,  I  am  reminded  of  a 
saying  of  my  former  preceptor,  the  late  Professor  Hughes  Bennett, 
of  Edinburgh,  who  was  wont  to  affirm  of  any  disorder  or  ailment 
for  which  long  lists  of  remedies  were  recommended,  that,  in  such 
cases,  we  were  probably  very  ignorant  of  the  true  nature  of  the 
disease  which  we  sought  to  control  or  combat. 

In  respect  of  gout,  as  of  other  maladies,  it  may,  however,  be 
confidently  stated  that  modern  advances  in  the  study  both  of 
morbid  anatomy  and  of  morbid  processes,  in  the  dead-house  and 
laboratory,  and  also  at  the  bedside,  have  rendered  the  therapeutic 
art  at  once  more  simple  and  less  uncertain. 

The  curability  of  gout  has  been  often  questioned,  and  great 
names  have  been  quoted  denying  such  possibility.  In  particular, 
Cullen  and  Trousseau  have  stated  their  belief  that  nothing  could 
be  safely  done  to  cure  acute  attacks ;  and  the  prescription  of 
"  patience  and  flannel "  of  the  former  physician  has  come  to  be 
proverbial  in  obstinate  cases,  both  of  gout  and  rheumatism. 

It  may  be  fairly  stated  that  for  many  years  no  difficulty  has 
been  experienced  in  successfully  treating  paroxysms  of  acute  gout, 
and  that  such  are  truly,  as  affirmed  by  Garrod,  as  controllable  and 
amenable  to  proper  remedies  as  any  other  inflammatory  affection. 

There  is  no  doubt  that,  either  with  the  inherited  or  acquired 
gouty  habit,  patients  are  liable  all  their  lives  to  more  or  less 
manifestation  of  the  dyscrasia  which  will  dominate  and  modify 
many  of  their  general  nutritional  processes.  Drugs  alone  cannot 
be  trusted,  once  and  for  all,  to  remove  a  gouty  habit  of  body.  It 
is  of  the  essence  of  this  malady  to  recur  and  grow  up  in  the 


346   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

system  from  time  to  time,  often  in  spite  of  all  regiminal  and 
other  precautions.  As  has  been  shown,  the  degree  of  impressi- 
bility by  this  or  by  any  other  diathesis  varies  infinitely  in  different 
individuals.  Much  may  be  done  by  diet  and  by  remedies  to  check 
the  tendency  to  recur,  but  it  is  too  commonly  the  case  that, — once 
gouty,  always  gouty. 

The  natural  history  of  a  fit  of  the  gout,  which  is  well-known, 
leads  to  the  belief  that  gout  in  this  sense  cures  itself,  and  is  Nature's 
way  out  of  the  trouble.1  This  is,  at  all  events,  so  far  true,  that  no 
countenance  can  be  given  to  any  therapeutic  efforts  which  would 
tend  to  abort  a  fit  once  established.  For  all  this,  the  physician 
cannot  consent  to  look  on  and  do  nothing  in  such  a  case,  any 
more  than  he  can  stand  idly  by  a  patient  suffering  from  pneu- 
monia or  one  ill  with  enteric  fever.2  There  is  much  to  be  done 
in  such  cases,  though  no  educated  physician  would  now  allow  that 
he  treated  the  diseases  in  any  one  of  them.  He,  of  course,  treats 
the  patient,  and  helps  him  through  his  diseases.  This  is  the 
rational  practice  of  physic  of  the  last  quarter  of  this  century. 

Again,  in  chronic  forms  of  gout  there  is  much  to  be  done  for 
the  patient  to  render  life  tolerable,  and  to  prevent  the  mischievous 
spread  of  the  morbid  processes. 

Much  discredit  has  been  brought  on  the  treatment  of  gout  and 
gouty  states  because  of  the  impatience  and  credulity  of  sufferers. 
They  will  not  submit  to  the  necessary  regimen  and  rest,  and 
they  are  too  ready  to  employ  any  nostrum  or  application  foisted 
on  them  by  ignorant  persons,  or  advertised  in  the  newspapers. 
Having  damaged  their  health  thereby,  they  come  under  rational 
treatment  at  a  great  disadvantage,  both  to  themselves  and  the 
practitioner. 

In  the  treatment  of  gout  it  is  essential  to  have  in  view  the 
whole  malady,  and  not  the  mere  accidents  of  it.  The  constitu- 
tional state  demands  unceasing  attention  in  every  case.  The 
patient's  attention  is  mainly  directed  to  the  painful  or  disabling 
episodes  of  his  case,  and  he  is  little  disposed  to  have  regard  to 
the  necessary  regime  called  for  in  his  daily  life  when  these  gouty 
outbursts  have  passed  away. 

Treatment  relates,  therefore,  to  the  active  phases  of  the  malady, 
and  to  the  patient's  condition  in  the  intervals  between  such 
attacks.  The  management  of  the  cachexia  induced  by  gout  in 
its  later  stages  relates  more  to  the  general  state  of  the  patient 

1  "  The  gout  is  the  only  cure  of  the  gout." — Mead. 

2  "Nature  seeks  a  relief  qua  detur porta,  and  the  physician  must  not  arrive  only 
to  forbid  it  and  to  lock  up  the  mischief."— IF.  Gairdner. 


SPECIFICS   FOR    GOUT.       COLCHICUM. 


547 


than  to  anything  specifically  due  to  the  clyscrasia  which   has  in- 
duced such  a  condition. 

I  propose  to  describe  :  ( I .)  The  treatment  proper  for  a  paroxysm 
of  regular  acute  gout;  (2.)  The  medicinal  and  other  treatment 
in  the  intervals  between  the  paroxysms;  (3.)  The  treatment  of 
chronic  and  irregular  gout;  (4.)  The  local  treatment  of  the 
joints  in  chronic  gouty  arthritis,  and  the  treatment  of  tophi ; 
(5.)  Treatment  of  retrocedent  and  incomplete  gout;  (6.)  The 
treatment  of  special  disorders  dependent  on  the  gouty  habit ; 
(7.)  Treatment  of  gouty  cachexia  and  of  gout  in  elderly  persons; 
(8.)  Preventive  treatment  of  gout. 

As  pointed  out  by  Sir  Thomas  Watson,  Heberden  looked  for- 
ward to  the  time  when  a  specific  for  gout,  as  certain  as  those  dis- 
covered for  ague  and  scabies,  would  be  found,  and  the  former  writer 
conceived  that  the  time  had  come  when  colchicum  was  proved  to  be 
of  its  known  utility  in  easing  the  pain  and  other  troubles  attaching 
to  gout.  The  "  inert  expectancy,"  as  he  terms  it,  of  Sydenham  and 
of  Oullen,  has  now  given  place  to  more  active,  if  still  empirical, 
measures,  and  with  decided  benefit  to  the  sufferer. 

It  is  remarkable  how  long  the  knowledge  of  the  value  of  this 
drug  lay  dormant.  It  was  well  known  in  the  sixth  century  as  a 
remedy  for  gout  under  the  name  of  Hermodactyls.1  It  appears 
probable  that  these  consisted  of  the  corms  of  a  variety  of  colchicum 
though  not  of  the  C.  autumnale.  Only  within  the  last  century  has 
the  latter  been  employed  in  practice,  and  no  other  variety  is  now 
made  use  of,  although  parts  of  other  plants  of  the  same  natural 
order  (Melanthacea?)  have  some  repute  in  the  treatment  of  gout. 

The  bitter  Hermodactyls  are  regarded  by  Planchon,  Dymock,  and  others  as 
being  the  corms  of  a  Colchicum  (Colchicum.  Variegatum).  By  the  courtesy  of  Mr. 
Carteighe,  President  of  the  Pharmaceutical  Society,  and  of  Mr.  Jackson,  of  Kew, 
three  authentic  specimens  of  this  form 
of  Hermodactyl  were  procured  from 
the  Kew  Museum  and  examined  by 
Professor  Dunstan  in  the  Research 
Laboratory  of  the  Pharmaceutical  So- 
ciety. (Fide  fig.  22.)  They  were  found 
to  contain  a  minute  quantity  of  an  al- 
kaloid, which,  however,  possessed  none 
of  the  properties  of  colchicina,  the  al- 
kaloid of  Colchicum  autumnale.  A  suffi- 
cient number  of  these  Hermodactyls 
could  not  be  obtained  to  investigate 
further  the  nature  of  the  alkaloid.  FlG'  22* 

The  Hermodactyls  of  Pereira  and  Guibourt  are  not  bitter,  and  are  yielded  most 
probably  by  a  species  of  Fritellaria.    In  fact,  they  are  not  the  corms  of  a  Colchicum. 


1  Recommended  by  Alexander  of  Tralles  (a  city  of  Lydia),  circ.  580    a.d.  (often 
quoted  by  van  Swieten). 


348   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

No  other  drug  has  effectually  displaced  colchicum  from  its 
pre-eminence  as  a  remedy  for  gouty  pain.  Within  recent  years 
the  claims  of  sodium  salicylate  have  been  pressed  in  various 
quarters,  and  this  most  valuable  addition  to  our  therapeutic 
armoury  in  the  case  of  rheumatic  fever  has  sometimes  displaced 
the  older  practice  of  exhibiting  colchicum  in  gout.  Of  this  more 
anon. 

1.— Treatment  of  Acute  Gout. 

An  attack  of  frank,  paroxysmal,  gout  constitutes  a  crisis  in  an 
aggravated  gouty  state  of  the  system,  and,  as  such,  is  a  severe 
symptomatic  expression  of  that  state. 

Abortive  Treatment. — The  idea  of  treating  gout  with  a  view  of 
aborting  it  could  not  occur  to  those  who  regard  it  from  a 
proper  pathological  stand-point.  Several  methods  have  been  pro- 
posed for  this  purpose.  Thus,  firm  pressure,  as  by  strapping  with 
diachylon  plaster,  applied  at  once  to  the  affected  part,  is  alleged 
to  give  relief  and  prevent  further  trouble.  Various  vaunted 
specifics  are  in  popular  use,  such  as  Laville's  liquor,  and  remedies 
of  like  kind,  supposed  to  contain  colchicum,  veratrina,  and  other 
anodynes.  Hypodermic  injection  of  morphine  in  the  neighbour- 
hood of  the  affected  part  is  another  such  remedy.1  In  despera- 
tion, patients  have  themselves  applied  snow  and  cold  applications 
to  banish  the  pain  and  local  disturbances.2 

Its  Undesirability. — Practical  acquaintance  with  the  disease 
affords  no  countenance  to  any  of  these  methods  of  treatment. 
The  risks  of  suppression  of  local  symptoms  are  so  great,  and  the 
benefit,  if  there  be  any,  so  dearly  bought  in  most  cases,  that  an 
ectrotic  treatment  can  seldom  be  advisable.3 

Cases  are  on  record  in  which  threatening  articular  attacks 
have  been  averted  by  the  exercise  of  strong  will.  Thus,  a  strong 
man,  feeling  an  acute  paroxysm  impending,  determines  to  "  fight 

1  Recommended  by  Dr.  D.  B.  Simmons,  of  Tokio,  Japan.  Medical  Record,  New 
York,  October  8,  1887,  p.  485. 

2  The  illustrious  Harvey,  and  Gregory,  of  Edinburgh,  resorted  to  this. 

3  Mr.  Teale  has  kindly  given  me  the  following  particulars  of  a  case  of  acute 
gout,  which  was  remarkably  and  successfully  aborted  by  morphine  given  subcutane- 
ously : — "A  lady,  a  cripple  in  her  hands  from  '  rheumatic  gout ' — unable,  I  believe,  to 
write  letters  for  two  or  three  years — was  in  great  suffering  from  a  more  acute  par- 
oxysm, affecting  hands,  arms,  and  shoulders.  She  was  moaning,  almost  screaming, 
with  pain,  and  utterly  helpless.  To  ease  the  pain,  I  injected  a  small  dose  of  morphia 
— an  |th  of  a  grain,  I  think.  Next  morning  her  gout  seemed  to  be  gone  ;  she  could 
move  her  hands  and  arms.  In  three  days  she  packed  up  her  clothes  herself,  and  took 
a  long  journey  ;  and  for  a  year  or  two  sent  messages  to  me  to  say  how  she  had 
regained  her  power  of  writing  and  had  lost  her  pain." 


TREATMENT  OF  ACUTE  GOUT.  349 

down  "  his  gout,  and  forthwith  steps  out  briskly  for  a  few  miles, 
and  "walks  off"  the  attack.  In  such  instances  we  may  take  note 
of  the  remarkable  influence  exerted  by  a  vigorous  nervous  system 
on  the  peculiar  phenomena  of  a  gouty  fit.  They  are  not  fre- 
quently to  be  met  with,  and  may  only  be  looked  for  in  persons 
of  robust  habit,  who  offer  strong  resistance  to  gouty  dyscrasia. 

The  measures  to  be  adopted  relate  to  an  illness  which  will  last 
from  one  to  two  weeks.  The  natural  history  of  an  acute  gouty 
access  is  well- ascertained. 

Treatment  must  be  local  and  palliative,  and  also  constitutional 
and  general.  As  in  all  diseases,  our  efforts  are  directed  to  the 
conduct  of  the  case.  We  do  not  treat  a  disease,  but  we  treat  a 
patient  with  a  disease.  The  individual  is  to  be  studied  in  each 
instance,  and  the  questions  to  be  answered  at  the  bedside  are : 
— What  will  the  disease  do  to  the  patient,  and  how  will  he 
bear  it  ? 

A  paroxysm  of  gout  must  be  treated  somewhat  differently, 
according  to  the  age,  state  of  constitution,  and  vital  powers  of 
the  individual  attacked.  Where  the  attack  is  regular  and  sthenic, 
the  degree  of  intensity  of  the  pain  and  inflammatory  symptoms, 
even  if  great,  never  warrants  severe,  or  what  are  termed  anti- 
phlogistic, measures.  Practice  of  this  kind  is  proved  to  be  bad, 
to  retard  recovery,  and  render  relapse  or  early  recurrence  of  fresh 
attacks,  probably  less  regular,  certain.  Hence,  general  blood- 
letting, or  local  depletion  by  leeching,  is  to  be  avoided.  The 
former  is  rarely  necessary,  and  the  latter,  according  to  Garrod 
and  others  who  have  had  experience  of  it,  is  harmful.  I  have 
several  times  seen  patients  whose  gouty  joints  had  been  leeched. 
In  one  case  six  leeches  did  no  good.  In  another,  four  leeches 
were  believed  to  bring  relief  in  twenty-four  or  thirty  hours. 

The  patient  must  remain  recumbent,  though  not  necessarily 
in  bed,  for  several  days.  This  is  of  great  importance.  The 
affected  limb  should  be  raised,  supported  on  a  firm  pillow,  kept 
warm,  though  lightly  covered,  and  protected  by  a  cradle.  A  thin 
layer  of  carded  cotton  wool,  invested  with  a  domet  bandage,  is  a 
grateful  application  for  most  cases.  Experienced  sufferers  tell  of 
relief  afforded  by  warm  spirituous  lotions  on  lint  covered  with 
oiled  silk — whisky  and  water  being  a  favourite  application.  A 
lotion  consisting  of  a  drachm  of  sulphuric  aether  in  six  ounces  of 
water  is  sometimes  found  soothing  {Pye-Smith).  The  intensity  of 
the  pain  often  suggests  the  employment  of  some  anodyne  lotion, 
and,  hence,  laudanum  and  water  in  various  proportions,  or  the 
combination  of  belladonna  liniment  with  morphia,  as  employed 


350   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

by  Garrod,1  and  which  I  have  found  useful,  may  be  prescribed. 
As  moist  applications  are  sometimes  uncomfortable  and  incon- 
venient, I  have  occasionally  used  anodynes  dissolved  in  oleic  acid 
with  decided  relief.2 

Iodoform  has  been  recommended  for  external  use  in  acute  gout, 
employed  as  ointment,  or  with  flexile  collodion.  Nitrate  of  silver, 
rubbed  over  the  affected  part,  is  well-spoken  of  by  some  practi- 
tioners. I  have  no  experience  of  either  of  these  local  methods  of 
treatment. 

The  unguentum  atropinse  (gr.i.  ad  3i.)  of  the  Pharmacopoeia 
is  available,  but  somewhat  less  manageable  than  the  oleate. 

The  application  of  oil  of  peppermint  has  been  recommended. 
I  have  no  experience  of  this  practice,  but  I  have  known  menthol 
in  a  spirituous  solution  to  be  employed  as  a  lotion,  and  to  suc- 
ceed when  other  anodynes  have  failed.3  Cocaine,  in  the  form  of 
liniment,  ointment,  or  lotion,  may  be  used.4  Flexile  collodium 
and  French  chalk  in  fine  powder  are  amongst  many  extolled 
local  anodynes.  I  believe  that  any  application  which  chokes  the 
sweat-ducts  is  undesirable  in  local  gouty  inflammation,  but  the 
truth  is,  that  relief  in  one  case  is  sometimes  gained  by  a  remedy 
which  will  quite  fail  to  afford  ease  in  another.  Occasionally,  I 
have  known  the  pain  of  gout  to  be  so  prolonged  and  atrocious, 
and  so  rebellious  to  all  local  measures,  including  strong  bella- 
donna and  laudanum  lotions,  that  little  relief  was  reached  till  the 
disease  had  well-nigh  run  its  course.  It  is  advisable  to  have  a 
variety  of  local  applications  at  our  disposal,  so  as  to  find  some 
one  that  may  prove  effectual. 

Poultices  are  sometimes  soothing,  and  warm  fomentations  like- 
wise. I  prefer  the  latter,  but  only  at  the  outset  of  an  attack,  as 
a  preliminary  measure  to  those  just  mentioned.  Blisters  are  not 
advisable  in  early  and  regular  articular  paroxysms,  but  find  a 
place,   if  skilfully  used,  in  some  phases  of  subacute  or  chronic 

1  R  Lin.  Belladonnas  fgiij-,  Morphinse  Hydrochloratis,  gr.x.  M.  utft.  Linimentum. 
Sig.  A  teaspoonful  to  be  mixed  with  a  tablespoonful  of  hot  water,  and  applied  on 
lint  under  oiled  silk  every  four  hours. 

2  R  Atropines  gr.iij.,  Morphinas  Hydrochloratis  gr.xv.,  Acidi  Oleici  fgi.  Solve  ut 
ft.  Linimentum.  Sig.  To  be  painted  over  the  painful  joint  with  a  large  camel's  hair 
brush,  and  carded  cotton  to  be  superimposed  with  a  domet  bandage. 

3  Three  parts  of  menthol  and  two  of  camphor  may  be  rubbed  up  together  to  form 
an  anodyne  application,  or  gss.  of  menthol  may  be  dissolved  in  fgvi.  of  spirit  of 
chloroform  for  a  lotion. 

4  R  Cocainas  gr.v.,  Paraffini  Mollis  5ij-     Solve,  calore  leni,  ut  ft.  Unguentum. 

R  Cocainas  gr.iv.,  01.  Amygdalae  Dulcis  fgss.  Solve,  calore  leni,  ut  ft.  Lini- 
mentum. 

R  Cocainae  gr.iv.,  Acidi  Oleici  f§ss.     Solve,  calore  leni,  ut  ft.  Linimentum. 


TREATMENT  OF  ACUTE  GOUT.  35 1 

gouty  arthritis.  They  should  be  applied  for  three  or  four  hours 
nightly  as  "  flying  "  blisters. 

For  internal  remedies,  it  is  well  to  begin  in  most  cases  with  an 
aperient  dose  of  calomel  and  colocynth  and  henbane  pill.  Strong 
purgation  is  improper,  and  may  aggravate  the  attack.  If  the 
belly  be  hard,  this  may  be  taken  as  an  indication  that  the  patient 
will  bear  purging.  A  reverse  condition  should  determine  against 
it.  This  is  an  old  and  very  true  observation.  One  or  two 
grains  of  calomel,  with  six  or  eight  of  the  above-mentioned  pill, 
should  suffice  over-night,  to  be  followed  by  a  Seidlitz  powder,  or 
four  ounces  of  Ptillna  or  of  other  saline  aperient  water,  taken 
warm,  early  the  following  morning. 

It  is  well  to  wait  till  the  attack  is  fully  manifested  in  the  part 
before  beginning  treatment  by  colchicum.  This  was  Sir  Henry 
Halford's  rule,  and  it  may  be  followed  implicitly.  The  wine  of 
the  corm  is  sufficiently  trustworthy,  though  the  tinctures  of  the 
seeds  and  of  the  flowers  have  their  advocates,  and  the  first  dose 
should  be  larger  than  subsequent  ones.  Thirty  to  forty-five 
minims  may  be  given  at  night,  and  half  the  dose  in  the  morning. 
Some  practitioners  affirm  that  colchicum  itself  is  sufficiently  ape- 
rient and  requires  no  combination  with  other  purgatives,  but 
general  experience  is  not  in  favour  of  this  practice.  Hence,  it  is 
well  to  add  twenty  grains  of  carbonate  of  magnesium  or  a  drachm 
of  the  sulphate  of  that  base  to  each  dose,  and  syrup  of  white  poppy, 
one  drachm,  and  camphor  mixture,  or  some  aromatic  water,  one 
ounce  and  a  half,  may  be  the  vehicle  of  it.1 

Great  benefit  may  be  sometimes  secured  from  a  dose  of  the 
mistura  sennas  composita,  to  which  half  a  drachm  of  the  wine  of 
colchicum  is  added.  This  draught  should  be  given  early  in  the 
morning  during  an  acute  attack.  This  may  replace  colchicum 
during  the  day. 

After  three  or  four  days  of  this  treatment,  two  pills  containing 
two  or  three  grains  of  the  acetous  extract  of  colchicum,  with  as 
much  compound  ipecacuanha  powder  and  compound  colocynth 
pill,  may  be  given  for  two  or  three  nights,  followed  up,  if  necessary, 
by  a  mild  purgative.  The  condition  of  the  tongue  is  commonly 
a  safe  guide  to  the  progress  of  the  case.  Marked  relief  to  the 
gouty  fit  will  rarely  accrue  till  the  tongue  begins  to  lose  its  coating. 

Treatment  of  acute  gout  by  colchicum  is  that  most  commonly 
practised.     The  works  of  most  authors  on  gout  tell  of  numerous 

1  The  Haustus  Colchici  of  the  St.  Bartholomew's  Hospital  Pharmacopoeia  is  a  well- 
proved  formula : — B.  Magnesii  Carbonatis  gr.x.,  Tinct.  Sem.  Colchici  iT]xx.,  Aq. 
Menth.  Virid.  ad  f§i. 


352   TREATMENT  OF  THE  SEVERAL  VARIETIES  OP  GOUT. 

untoward  effects  produced  by  this  remedy,  and  contain  grave  warn- 
ings against  over,  or  too  prolonged,  dosing  with  it.  It  is  probable 
that  the  drug  has  been  little  abused,  certainly  of  late  years,  by 
professional  hands,  and  many  of  the  evils  referred  to  have  doubt- 
less ensued  when  it  has  been  taken  on  the  patient's  own  respon- 
sibility, either  overtly  or,  rudely,  in  the  form  of  some  nostrum.  I 
have  never  myself  had  any  experience  of  undesirable  effects  from 
the  use  of  colchicum.  Sir  George  Burrows  was  wont  to  employ 
it  sometimes  freely,  but  I  never  saw  more  severe  results  than 
purging  with  the  characteristic  green  stools.1  Both  practitioners 
and  patients  appear  sometimes  to  expect  too  much  from  this  drug, 
and  there  is  temptation  to  press  it  in  certain  cases,  especially 
when  it  is  desirable  to  render  a  patient  fit  for  some  duty  or 
appointment  by  a  definite  day. 

Gouty  persons  should  be  warned  of  the  imprudence  of  con- 
ducting their  own  cases  with  this  or  with  any  other  drug,  and 
be  especially  put  on  their  guard  against  resorting  to  reputed 
specifics,  most  of  which  contain  colchicum  or  its  congener  veratrina. 

The  wine  of  the  corm  of  colchicum  is  that  most  frequently 
employed.  It  is  the  least  satisfactory  in  appearance  of  all  the 
liquid  preparations  of  the  drug,  precipitating,  as  does  ipecacuanha 
wine,  a  sediment,  and  seldom  being  bright.  The  sediment  has 
been  found  inert  as  a  remedy  in  gout. 

Preparations  of  the  seeds  are  more  purgative  than  those  of  the 
corm.  Hence,  according  to  Dr.  Eobertson,  the  dose  of  the  for- 
mer should  be  smaller — twenty  as  against  thirty  minims.  A 
grain  of  dried  corm  is  contained  in  five  and  a  half  minims  of 
the  wine,  and  nine  minims  of  the  tincture  contain  one  grain  of 
the  seeds. 

Battley's  liquor  colchici  recentis  contains  one  grain  of  solid 
extract  of  the  corm  in  eight  minims,  or  the  equivalent  of  fourteen 
minims  of  the  wine.  The  extract  and  acetous  extract  may  be 
given  in  doses  of  half  a  grain  to  two  grains. 

There  is  a  compound  tincture  of  colchicum  which  is  preferred 
by  some  practitioners.  It  should  rather  be  called  an  ammoniated 
tincture,  since  it  is  made  by  macerating  the  seeds  of  colchicum 
in  aromatic  spirit  of  ammonia.  I  have  no  experience  of  its 
value. 

Veratrina  and  colchicina  have  both  been  employed  internally 
and  locally  in  acute  gout.  The  former  was  employed  by  Dr. 
Turnbull  as  an  external  application.  Twenty  to  forty  grains  of 
either  may  be  mixed  with  an  ounce  of  spermaceti  ointment,  or 

1  In  appearance  these  have  been  likened  to  green  pea-soup. 


ACTION    OF   COLCHICUM.  353 

the  same  quantity  may  be  dissolved  in  an  ounce  of  rectified  spirit 
and  applied  with  a  camel's  hair  brush.  Oleic  acid  may  also  be 
used  instead  of  ointment  or  spirit. 

These  two  alkaloids  are  generically  allied.  Veratrina  causes 
violent  sneezing,  while  colchicina  does  not.  I  have  employed  the 
former  with  benefit  as  a  local  application  in  gout,  but  have  never 
administered  it  internally. 

In  a  case  of  painful  gout  of  the  knee-joint,  I  applied  a  lotion 
of  equal  parts  of  tincture  of  colchicum  seeds  and  water  on  lint 
under  gutta-percha  tissue.  No  relief  was  obtained,  and  a  red 
papular  rash  came  out  on  the  skin  in  consequence.  In  this  case, 
an  arnica  lotion,  one  part  of  the  tincture  to  eight  of  water,  applied 
for  several  days,  induced  no  rash  on  other  parts  of  the  skin,  as 
commonly  met  with  in  gouty  persons. 

In  a  case  of  painful  gouty  finger-joints  with  a  "  crab's-eye  " 
(inflamed)  bursa,  a  colchicum  lotion  was  found  very  soothing. 

The  explanation  of  the  specific  effects  of  colchicum  on  gout 
and  gouty  pain  is  not  yet  forthcoming.  There  are  several  theo- 
ries as  to  its  action.  Much  discrepancy  exists  in  the  accounts 
given  by  different  observers  as  to  its  influence  on  excretion  both 
of  urea  and  uric  acid,  due,  as  suggested  by  Lauder  Brunton,  to 
experimentation  being  carried  out  while  different  diets  were 
employed.  A  small  dose  increases  gastro-intestinal  secretion, 
while  a  larger  one  causes  nausea  and  diarrhoea,  lessens  muscular 
irritability,  and  paralyses  the  central  nervous  system.  The  blood- 
pressure  sinks  gradually  in  consequence  of  lowering  of  the  irri- 
tability of  the  vaso-motor  centres.1 

Professor  Rutherford,  of  Edinburgh,  has  conclusively  proved 
that  colchicum  in  large  doses  is  one  of  the  most  powerful  true 
cholagogues  known,  the  bile  being  also  rendered  more  watery  by 
it.2  Its  aperient  properties  are  very  marked,  and,  hence,  it  is 
often  a  valuable  addition  to  other  aperients  for  ordinary  pur- 
poses. 

Its  active  principle,  colchicina,  has  been  employed  in  gout  with 
alleged  benefit.  It  is  very  powerful,  and  can  only  be  prescribed 
in  doses  varying  from  a  sixtieth  to  a  fifteenth  of  a  grain,  dis- 
solved in  water,  hypodermically,  or  by  the  mouth.  A  solution  of 
one-twentieth  of  a  grain  in  twelve  minims  of  distilled  water  may 
be   used  for  subcutaneous  injection,  four  to  eight  minims  being 

1  Schmiedeberg. 

2  Post-mortem,  the  mucous  membrane  of  dogs'  intestines  was  found  intensely  vas- 
cular after  injections  of  drachm  doses  of  extract  of  the  corm.  The  intestinal  glands 
were  stimulated  as  well  as  the  liver  {Rutherford). 

Z 


354   TREATMENT  •  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

thus  employed.  I  have  never  had  occasion  to  try  this  method, 
and  being  strongly  averse  from  all  forms  of  hypodermic  medica- 
tion, save  when  indispensable,  I  am  not  likely  to  employ  it. 

In  many  gouty  patients  it  is  far  from  advisable  to  injure  the 
integuments,  even  by  a  needle,  and  as  the  best  results  of  the 
whole  drug  can  be  obtained  in  the  usual  fashion,  I  see  no  advan- 
tage in  resorting  to  this  inconvenient  and  painful  plan  of  giving  it. 

It  is  certain  that  all  the  benefits  sought  from  colchicum  can 
be  obtained  without  producing  in  the  patient  any  very  note- 
worthy physiological  effects.  In  other  words,  the  specific  power 
of  the  drug  over  gouty  arthritis  may  be  secured  without  the 
induction  of  depression,  nausea,  or  untoward  purging.  Sweating 
is  sometimes  caused,  but  this  is  not  undesirable.  Colchicum  is 
a  vascular  depressant,  the  frequency  and  force  of  the  pulse  being 
reduced  by  it,  and  with  the  lowering  of  arterial  tension  comes 
relief  to  the  circulation  in  the  inflamed  joint.  As  a  remedy,  the 
drug  is  depressing,  in  proportion  to  the  dose  and  length  of  time  it 
is  given.  The  indication,  therefore,  is  to  employ  as  much  as,  and 
no  more  than,  will  control  the  urgent  symptoms,  and  not  to  con- 
tinue its  use,  unless  in  small  doses,  longer  than  is  necessary. 

The  anodyne  effects  are  those  especially  to  be  sought,  and  with 
these  are  associated  the  other  specific  and  beneficial  actions  of 
the  remedy.  Relief  is  usually  forthcoming  before  the  occurrence 
of  "  colchicum  stools."  As  already  stated,  some  practitioners 
trust  to  colchicum  for  such  aperient  effects  as  may  be  desirable 
in  any  case  of  acute  gout.  The  objection  to  this  is  that,  to  ensure 
sufficient  purgation  in  many  cases,  it  is  necessary  to  employ  far 
larger  doses  of  the  drug  than  are  needed  only  to  control  the  pain, 
and  colchicum  purging  is  especially  lowering  and  depressant. 
As  a  result  of  such  depression,  the  system  is  little  able  to  resist 
fresh  onsets  of  gout,  which  are  therefore  more  apt  to  recur  after 
a  short  interval.1 

The  experience  of  most  practitioners  is  that,  given  with  pru- 
dence, no  evil  effects  are  apt  to  follow,  and  no  special  proneness  to 
renewed  attacks  is  thereby  established.  Occasional,  but  moderate, 
purgation,  with  mercurials  given  at  bedtime,  is  of  great  value  in 
acute  gout,  especially  in  sthenic  cases,  and  before  the  age  of 
sixty.  The  good  effects  of  colchicum  are  not  exclusively  due  to 
its  action  as  a  vascular  depressant,  since  other  agents  which  lower 
blood-pressure  will  temporarily  relieve  the  pain  of  gout. 

Garrod  made  some  very  careful  observations  in  gouty  patients 

•  1  "  Drachm  doses  of  the  wine  may  be  given  with  no  effect  upon  the  disease,  but 
with  sad  disturbance  to  the  patient's  system." — W.  Gairdner. 


ACTION    OF   COLCHICUM.  355 

on  the  action  of  colchicum  in  respect  of  its  power  over  excretion 
of  uric  acid  and  urea.  As  a  result,  he  affirms  that :  ( i .)  It  does 
not  appear  that  the  drug  produces  any  of  its  effects  on  the 
system  by  causing  the  kidneys  to  eliminate  an  increased  quantity 
of  uric  acid.  When  it  is  continued  for  any  length  of  time,  it 
appears  to  exert  a  contrary  effect.  (2.)  It  cannot  be  shown  that 
the  drug  has  any  influence  on  the  excretion  of  urea  or  other  solid 
ingredients  of  the  urine.  (3.)  It  does  not  act  as  a  diuretic  in 
all  cases,  but,  on  the  contrary,  diminishes  the  amount  of  urine 
when  it  induces  purging. 

I  am  of  opinion  that  a  large  part  of  the  beneficial  effect  of 
colchicum  in  gout  is  due  to  its  decided  action  on  the  liver. 
Powerful  cholagogue  action  necessitates  active  hepatic  metabolism, 
and  with  this  is  secured  a  more  complete  disposal  of  uric  acid 
and  other  products,  which  are  believed  with  good  reason  to  be 
retained  in  the  liver  in  cases  of  gout.  Dr.  Lauder  Brunton  sug- 
gests that  colchicum  affects  the  ferments  by  whose  action  uric 
acid  is  formed,  and  so  lessens  the  production  of  that  acid.  He 
believes  that  it  also  paralyses  the  sensory  nerves,  but  has  no 
action  on  motor  nerves  or  muscles.  Dr.  Latham  thereupon  sug- 
gests that  if,  in  gouty  fits,  uric  acid  is  irritating  the  sensory 
nerves,  and  through  them  the  more  active  portion  of  the  vaso- 
motor centre,  we  may  paralyse  the  sensory  nerves  with  colchicum, 
so  that  the  uric  acid  no  longer  produces  its  effect,  and  the 
paroxysm  ceases.  The  drug,  therefore,  probably  acts  in  more 
ways  than  one,  possessing  not  only  specific  anodyne  properties, 
due,  perhaps,  largely  to  its  action  as  a  vascular  depressant,  but 
also  the  power  of  hastening  and  modifying  hepatic  and  other 
tissue-metabolism,  together  with  an  eliminant  property. 

According  to  Dr.  Robertson,1  of  Buxton,  whose  experience  of 
gouty  patients  and  their  treatment  has  been  very  large,  the  action 
of  colchicum  is  greater  and  more  decided  on  the  local  manifes- 
tation of  gout  and  the  inflammatory  nature  of  the  paroxysm,  than 
on  the  constitutional  condition  on  which  gout  depends,  and  of 
which  the  local  ailment  is  only  a  form  and  development.  He 
regards  the  drug  as  a  specific  for  gouty  inflammation  or  gouty 
localization,  and  not  as  influencing  the  condition  of  body  which  is 
the  proximate  cause  of  gout.  He,  like  Halford  and  Holland,  is 
strongly  in  favour  of  waiting  till  an  early  attack  is  well-established 
before  exhibiting  the  drug.  When  the  fits  have  been  frequent 
and  severe,  and  the  parts  are  already  the  seat  of  chronic  gout, 

1  The  Nature  and  Treatment  of  Gout.    Lond.,  1845. 


356   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

the  earlier  in  the  paroxysm  colchicum  is  prescribed,  the  more 
usefully  it  acts. 

Its  influence  on  the  sequelse  of  the  fit  and  in  diminishing  the 
liability  to  its  return  may  be  best  secured  by  small  doses  of  the 
drug.  These  may  be  continued  for  a  long  period,  if  necessary, 
without  any  harmful  effects.  Sir  Henry  Holland  was  in  the  habit 
of  employing  small  doses  for  months  at  a  time — in  one  case  it 
was  given  for  two  years — with  entire  exemption  from  gout  and 
benefit  to  the  general  health  of  the  patient,  who  was  formerly 
seldom  free  for  more  than  two  months  at  a  time  from  an  attack. 
He  generally  combined  small  doses  of  quinine  with  colchicum, 
when  given  over  a  long  period.  Sir  Thomas  Watson  was  con- 
vinced of  the  value  of  continued  small  doses  of  the  drug  in  chronic 
gout. 

For  fifteen  years  I  treated  numerous  cases  of  acute  gout  amongst 
the  out-patients  of  the  Hospital  with  little  else  than  the  colchicum 
draught  of  our  Pharmacopoeia,  and  I  had  good  reason  to  be  well- 
satisfied  with  the  practice.  In  the  majority  of  cases  no  other  plan 
of  treatment  answered  so  well.1  I  have  found  benefit  from  long- 
continued  dosage  in  chronic  gout,  e.g.,  five  or  six  minims  of  the 
wine  or  tincture  twice  a  day,  or  a  grain  of  the  acetous  extract  in 
pill  at  night. 

Many  cases  of  acute  gout  may,  however,  be  efficiently  treated 
without  colchicum.  Bicarbonate  and  nitrate  of  potassium  some- 
times prove  serviceable,  and,  on  subsidence  of  the  fit,  iodide  of 
ammonium  may  be  given.  Mercury  in  alterative  doses  may  be 
advantageously  prescribed,  both  during  and  after  the  attack  in 
many  cases. 

The  Salts  of  Salicylic  Acid  as  Anti-Gouty  Remedies. — Within  the 
last  twelve  years  the  salicylates  have  been  much  employed  in 
the  treatment  of  acute  and  chronic  gout.  M.  Germain  See  was 
one  of  the  first  to  publish  his  experience,  and  he  is  a  strong 
advocate  of  their  value,  believing  that  they  favour  the  elimination 
of  uric  acid.2  He  became  convinced  of  their  superiority  to  col- 
chicum, which  he  thought  disposed  to  chronic  gout,  and  regarded 
salicylate  of  sodium  as  of  equal  value  in  acute  gout  as  in  acute 
rheumatism.  Jaccoud  is  also  convinced  of  the  good  effects  pro- 
curable by  this  drug. 

About  the  same  time,  the  late  Dr.  Barclay  made  trial  of  sali- 

1  Of  this,  as,  indeed,  of  many  other  therapeutic  methods,  I  am  often  disposed  to 
say  with  Bianca  : — "  Old  fashions  please  me  best ;  I  am  not  so  nice,  to  change  true 
rules  for  new  inventions." — Taming  of  the  Shrew,  Act  iii.  scene  I. 

2  Progres  Medical,  1877,  p.  745. 

3  Ibid.,  p.  528. 


SODIUM    SALICYLATE    AS    A    REMEDY.  357 

cylic  acid  and  salicylates  in  cases  of  gout  in  St.  George's  Hospital,1 
and  expressed  the  opinion  that  they  had  nothing  like  the  same 
prompt  and  decided  action  as  seen  in  acute  rheumatism  when 
thus  treated.  The  effects  were  not  so  satisfactory  as  to  permit 
colchicum  to  be  dispensed  with.  Dr.  Barclay  found  that  when 
a  patient  was  susceptible  to  the  influence  of  colchicum,  the  latter 
had  certainly  a  more  definite  action  in  eradicating  the  disease, 
but  he  thought  that  salicylate  of  sodium  might  be  of  value  when 
the  attacks  grew  more  repeated,  and  colchicum  lost  its  good  effect. 
He  pointed  out  that  gout  was  sometimes  grafted  later  in  life  on 
true  rheumatism,  and  that  thus  salicylates  might  prove  of  especial 
value  in  such  instances. 

The  experience  of  Dr.  Ralfe  is  in  favour  of  salicylates  in  reliev- 
ing minor  gouty  manifestations  after  the  subsidence  of  violent 
paroxysms,  and  he  prefers  them  to  colchicum. 

I  have  tried  sodium  salicylate  in  a  considerable  number  of 
cases  of  acute  gout,  and  my  experience  is  that  it  is  in  most 
instances  very  inferior  to  colchicum  as  a  drug  to  relieve  the 
urgent  symptoms.  I  have  made  inquiry  from  other  physicians, 
and  find  their  general  experience  agrees  with  my  own.  In  a 
few  cases  I  have  certainly  met  with  marked  benefit  from  sodium 
salicylate  when  colchicum  had  completely  failed ;  but  I  could  not 
predicate  the  particular  case  in  which  one  should  fail  and  the  other 
succeed.  Dr.  Haig  is  of  opinion  that  if  salicylates  be  used  as 
freely  for  gout  as  for  acute  rheumatism,  veiy  satisfactory  results 
will  be  secured,  and  he  believes  that  in  most  cases  where  it  has 
failed,  the  drug  has  not  been  sufficiently  pushed. 

The  sodium  salt  is  the  best  to  employ.  Salicylate  of  lithium 
and  salicylate  of  quinine  have  been  employed  with  alleged  benefit. 
In  each  of  the  latter  the  amount  of  salicylic  acid  is  probably  too 
small  to  be  the  really  beneficial  agent,  and  any  good  effects  are 
presumably  due  to  the  lithium  or  the  quinine. 

The  careful  researches  of  Dr.  Haig  on  the  action  of  salicylate 
of  sodium  in  promptly  removing  headache  due  to  urichsemia,  and 
in  reducing  the  tension  of  the  pulse  which  is  common  in  gouty 
conditions  of  the  system,  are  very  significant  of  the  general  thera- 
peutical value  of  the  drug  in  gout. 

Many  practitioners  prescribe  alkalies,  together  with  salicylate 
of  sodium,  and  often  combine  ammonia  to  counteract  its  depress- 
ing effect  on  the  heart.  In  such  cases  it  is  not  possible  to  judge 
of  the  true  value  of  the  drug. 

It  should  not  be  given  if  the  kidneys  are  unsound,  and  this  is 

1  St.  George's  Hospital  Reports,  vol.  ix.,  1877-78. 


358   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

a  contra-indication  which  must  often  be  present  in  dealing  with 
acute  paroxysms  in  elderly  and  other  patients.  Albuminuria  is 
sometimes  induced  by  salicylate  of  sodium  in  healthy  persons, 
and  is  aggravated  if  it  already  exists  in  others. 

According  to  M.  Bouloumie,1  salicylate  treatment  is  well-adapted 
for  gout  in  the  young,  where  there  is  no  debility  nor  tendency  to 
nervous  depression.  M.  See  employed  three  drachms  daily  for 
the  first  three  days,  two  drachms  daily  for  the  next  three  days, 
and  alternated  these  doses  in  courses  each  of  three  days  for  three 
weeks.  This  treatment  must  be  considered  somewhat  heroic  if 
it  is  to  be  followed  as  a  matter  of  routine.  As  with  colchicum, 
it  is  well  to  observe  the  tolerance  in  each  case  for  the  drug, 
and,  in  particular,  to  ascertain  the  measure  of  renal  adequacy. 
I  have  already  mentioned  the  case  of  a  man  under  my  care 
suffering  from  acute  gout  in  several  joints,  with  much  sweating, 
who  derived  no  relief  from  colchicum,  but  was  at  once  relieved 
by  sodium  salicylate  given  as  for  acute  rheumatism.  Another 
case  of  chronic  tophaceous  gout  in  a  woman  under  my  care, 
in  whom  acute  attacks  supervened  from  time  to  time,  was  also 
markedly  benefited  by  this  treatment.  Dr.  Haig  has  recorded 
this  case  in  the  St.  Bartholomew's  Hospital  Reports  for  1888,  vol. 
xxiv.  p.  217.  His  view  is,  that  salicylate  seizes  upon  the  uric 
acid,  and  carries  it  off  from  the  system  as  a  soluble  salicylurate  by 
the  urine,  and  he  has  shown  that,  while  the  blood  is  impregnated 
with  the  drug,  neither  food  nor  acids  taken  are  potential  to  induce 
uric  acid  disturbances  as  evinced  by  headache  or  overt  goutiness. 
He  admits  that  it  sometimes  has  no  prompt  action  in  acute  gout. 
Ordinary  acids  lessen  the  solubility  of  uric  acid.  Salicylic  acid 
increases  urinary  acidity,  but  does  not  diminish  the  excretion  of 
uric  acid.2  Salicyluric  acid  is  much  more  soluble  in  water  than 
uric  acid,  and,  probably,  in  dilute  acids. 

Dr.  Haig  has  shown  that  uric  acid  is  present  with  salicyluric 
acid  in  the  urine  passed  after  salicylates  have  been  taken,  and 
believes  that  this  is  due  to  their  action  on  the  uric  acid  in  the 
blood,  and  not  on  that  excreted  directly  by  the  kidneys. 

The  action  of  salicylates  is  probably  effective,  both  by  reason  of 
their  chemical  properties  and  by  their  ability  to  dispose  of  the  uric- 
haemic  state.  Like  colchicum,  salicylic  acid  is  a  powerful  hepatic 
stimulant,  increasing  the  quantity  of  bile,  and  also  rendering  it 
more  watery.  It  is  also  a  vascular  depressant,  and  so  far  assists 
in  allaying  the  pain  of  an  acute  inflammatory  fluxion. 

1  Union  Medicate,  May  15,  1879. 

2  Trans.  Roy.  Med.  and  Chirurg.  Soc,  1888. 


SODIUM    SALICYLATE    AS    A    REMEDY.  359 

It  does  not  always  afford  relief  so  rapidly,  even  when  success- 
ful, as  does  colchicum,  and  not  till  after  a  day  or  two  is  its 
efficacy  appreciated,  at  all  events  by  the  patient.  In  some  cases, 
however,  it  acts  promptly  and  decidedly.  I  do  not  think  it  is 
likely  to  supersede  the  well-established  value  of  colchicum  as  a 
prompt  deliverer  from  the  agony  of  a  gouty  paroxysm  ;  but  it  is  a 
remedy  of  considerable  power  and  usefulness,  by  favouring  excre- 
tion of  uric  acid,  and  preventing  other  acids  in  the  system  from 
causing  retention  of  the  latter. 

Ebstein's  experience  of  this  agent  is  not  satisfactory.  He 
found  that  gouty  inflammation  tended  to  shift  quickly  from  one 
joint  to  another  when  the  patient  was  kept  under  the  influence  of 
the  drug. 

Lecorche"  finds  it  inferior  to  colchicum,  and  without  power  to 
shorten  the  attack.  It  lessened  the  pain  and  violence  of  the 
paroxysms,  and  within  a  day  or  two  promoted  a  large  excretion  of 
urea,  phosphoric  and  uric  acids.  This  excretion  he  found  to  last 
for  three  or  four  days,  when  gradual  diminution  set  in.  He  pre- 
scribes four  to  six  grammes  in  the  day ;  and  in  chronic  gout  with 
visceral  troubles,  save  when  there  is  interstitial  nephritis,  he 
maintains  this  medication  for  months  with  intervals  of  a  few  days 
after  each  fortnight.  Bouchard  is  in  favour  of  this  treatment  for 
acute  gout,  but  declines  to  employ  it  if  there  be  signs  of  cardiac 
or  renal  degeneration. 

Professor  Latham  is  a  strong  advocate  of  the  use  of  the  salicylates 
in  gout  with  the  precautions  already  mentioned.  His  theory  of 
their  beneficial  action  is  that  they  seize  on  glycocine,  or  its  ante- 
cedent, and  so  prevent  formation  of  uric  acid.  Dr.  Noel  Paton 
has  also  found  that  salicylates  diminish  the  excretion  of  uric  acid. 
This  view  is  not  in  agreement  with  the  observations  of  Lecorche 
and  Dr.  Haig,  who  found  increased  excretion  of  uric  acid. 

Of  the  value  of  medication  by  salicylates  in  doses  sufficient  to 
secure  relief  in  this  fashion,  I  feel  grave  doubt.  Bearing  in  mind 
the  marked  intolerance  of  some  patients  for  the  drug,  and  the 
severe  symptoms  sometimes  produced,  I  am  inclined  to  think  that 
the  remedy  may  be  worse  than  the  disease,  and  that  in  respect  of 
the  patient — cegrescit  medendo.  The  treatment  is  certainly  dis- 
agreeable, and  many  experienced  gouty  patients  would  refuse  to 
submit  to  it. 

For  some  phases  of  chronic  gout  smaller  doses  certainly  prove 
beneficial,  and  may  be  combined  with  alkalies. 

Of  the  use  of  salicin  in  any  form  of  gouty  disorder  I  have  no 
1  Journal  of  Anatomy  and  Physiology,  January  1886,  p.  26-32. 


360      TREATMENT    OF   THE    SEVERAL    VARIETIES    OF    GOUT. 

experience.  Antifebrin  (acetanilide)  is  a  modern  remedy  alleged 
to  have  considerable  power  in  relieving  acute  paroxysms  of  gout. 
The  dose  recommended  is  eight  grains  three  or  four  times  in  the 
day.      I  have  no  experience  of  its  value. 

Oases  are  met  with  in  which  no  relief  to  the  pain  of  acute 
gout  is  afforded  by  colchicum.  Patients  are  apt,  when  their 
advisers  fail  to  secure  decided  mitigation  of  their  suffering,  to 
resort  to  some  nostrum,  and  it  must  be  conceded  that  some  of 
these  succeed  when  regular  means  prove  unavailing.  The  fault 
probably  lies  at  our  own  door.  Insufficient  dosage  with  suitable 
remedies  may  be  a  cause  of  failure.  Neglect  of  purging  and  of 
mercurial  remedies  will  certainly  account  for  some  inadequacy 
of  bedside  art.  Patients  tell  of  relief  secured  by  some  vaunted 
nostrum ;  but  the  benefit  is  probably  not  far  to  seek  in  such  in- 
stances, and  consists,  generally,  in  the  employment  of  drugs  which 
both  purge  and  allay  pain,  the  remedies  being  taken  in  sufficient 
amount  to  secure  the  needed  effect.  A  fuller  dose  of  colchicum, 
with  a  purge  of  calomel  and  colocynth,  was  all  perhaps  that  was 
needed.  We  must  not  follow  the  patient  in  his  belief  that  he 
found  in  his  specific  any  drug  unknown  to  the  regular  profes- 
sion, for  no  such  agent  exists,  and  it  is  perfectly  well-known 
that  the  various  nostrums  for  gout  are  compounded  of  certain 
aperients  together  with  colchicum  or  some  preparation  of  white 
hellebore. 

The  measure  of  relief  found  by  any  gouty  patient  from  a 
vaunted  specific  is,  therefore,  the  measure  of  our  own  inefficiency 
as  clinical  physicians.  It  is  probable  that  none  of  these  specifics 
of  the  shops  are  harmful  in  themselves ;  but  inasmuch  as  they 
are  not  prescribed  by  regular  practitioners,  and  are  taken  by 
patients  themselves  on  their  own  responsibility,  they  are  used 
in  excess,  and  otherwise  improperly.  I  have  seen  many  gouty 
patients  who  had  thus  dosed  themselves  with  several  varieties 
of  these  nostrums,  and  some  of  them  appeared  the  worse  in  conse- 
quence. In  these  cases,  very  simple  and  ordinary  treatment  for 
gout  quickly  sufficed  to  procure  relief. 

A  fallacy  attached  to  the  use  of  these  agents  is  that  no  re- 
striction in  diet  is  necessary  while  suffering  from  gout,  and,  hence, 
the  attempt  is  fruitlessly  made  to  cure  the  disorder  while  ordinary 
or  excessive  indulgences  are  continued. 

Alkalies  in  Acute  Gout The  condition  of  the  blood  in  gouty 

states  has  for  a  long  period  led  to  the  employment  of  alkaline 
remedies  to  rectify  it,  and  they  may  fairly  be  credited  with  thera- 


ALKALINE    TREATMENT.  36  I 

pen  tic  power  of  high  order.  They  are  when  freely  diluted  rapidly 
absorbed,  and  pass  through  the  system  mainly  by  way  of  the 
kidneys.  Preference  is  given  to  the  salts  of  potassium,  am- 
monium, lithium,  and  sodium,  the  first  two  being  most  used. 
The  employment  of  alkalies  in  gout  relates  to  the  carbonates, 
bicarbonates,  and  citrates,  and  also  to  the  phosphates  of  sodium 
and  ammonium.  The  carbonates  and  bicarbonates  neutralize  any 
free  acidity  in  the  alimentary  canal  before  excretion  by  the  kid- 
neys. The  neutral  citrates  and  tartrates  are  discharged  as  car- 
bonates. Phosphates  pass  out  in  the  same  form.  The  potassium 
salts  possess  diuretic  properties,  and  form  more  soluble  combina- 
tion with  uric  acid.  Some  gouty  persons  cannot  take  sodium 
salts  without  aggravation  of  their  state.  Potassium  citrate,  acetate, 
and  bicarbonate  are  the  most  valuable  salts  to  employ  in  acute 
gout.1  The  dose  varies  from  fifteen  to  thirty  grains  of  each,  and 
should  always  be  given  well-diluted.  Distilled  water,  plain  or 
carbonated,  is  of  use  when  alkaline  remedies  are  prescribed  as  a 
diluent,  and  may  be  given  in  conjunction  with  colchicum,  sali- 
cylates, or  any  other  treatment  in  acute  gout.  Water-drinking 
unquestionably  aids  in  washing  out  urates  from  the  blood,  and 
aids  all  methods  used  for  this  purpose. 

The  key-note  of  all  treatment  in  any  gouty  state  is  to  seize 
upon  the  uratic  excess  or  stasis  in  the  system,  to  keep  it  moving, 
and  to  promote  its  elimination  by  every  channel.  Parkes  found 
that  potassium  citrate  caused  in  gouty  cases  large  elimination  of 
urea  and  of  phosphoric  acid,  while  sulphuric  acid  was  also  excreted 
in  excess.2 

Lithium  salts,  first  introduced  by  Garrod  in  1858,  are  of  great 
value  in  gout,  but  do  not  enable  other  approved  methods  of  treat- 
ment to  be  dispensed  with  in  the  first  instance.  They  form  the 
most  soluble  of  all  salts  of  uric  acid,  and  possess  more  neutralizing 
power  than  those  of  any  other  alkali.  Five  to  ten  grains  of  the 
citrate  or  carbonate  may  be  given,  alone  or  combined  with  potas- 
sium salts.  Lithia  water  may  be  used,  containing  five  grains  in  ten 
ounces,  to  the  extent  of  three  or  four  bottles  each  day  in  any  case 
of  gout  as  an  ordinary  drink.  No  harmful  effects  have  been 
observed  from  its  use.  On  the  whole,  it  is  a  remedy  better 
adapted  to  chronic  than  to  acute  phases  of  gout.  Hard  potable 
waters  are  best  avoided,  as  a  rule,  by  the  gouty.  The  lime  con- 
tained in  most  of  them  is  commonly  noxious,  and  tends  to  form 

1  A  formula  much  in  use  is  the  following  : — R  Potassii  Bicarb,  gr.xv.  ;  Vin.  Colch. 
rti,xv.  ;  Aq.  Menth.  Pip.  fgi.     M.  fiat  Haustus  ter  die  sumendus. 

2  On  the  Urine,  p.  297. 


362       TREATMENT    OF    THE    SEVERAL   VARIETIES    OF    GOUT. 

very  insoluble  salts  with  uric  acid.1  I  have  certainly  observed 
gouty  patients  who  drink  them  grow  worse  and  more  liable  to 
varieties  of  uric  acid  disturbance. 

Magnesium  salts  are  certainly  useful  in  acute  gout ;  but  after 
the  paroxysm  has  subsided,  it  is  proper  to  suspend  their  use  and 
resort  to  potassium  salts.  The  latter  should  be  given  on  an 
empty  stomach.  It  is  often  useful  to  vary  the  alkali  employed 
during  the  course  of  the  disorder.  Colchicum  is  a  valuable 
adjunct  to  them  in  many  cases. 

Phosphate  of  sodium  is  of  particular  value  in  gouty  states,  pro- 
viding an  excellent  and  natural  solvent  for  uratic  excess  in  the 
system.      It  is  tasteless,  and  acts  as  a  mild  aperient. 

Dr.  Haig  finds  it  almost  impossible  to  procure  specimens  free 
from  sodium  sulphate,  and  has  noted  that  this  impurity  retards 
the  desirable  effects  of  the  salt  to  a  considerable  degree.  With 
the  chemically  pure  drug  he  has  obtained  very  good  results  in 
respect  of  elimination  of  uric  acid.  The  dose  is  from  two  drachms 
to  half  an  ounce  three  or  four  times  a  day. 

Ammonium  phosphate  acts  much  as  does  the  sodium  salt, 
but  is  beneficial  where  a  slight  stimulant  action  is  desirable. 
It  may  be  given  in  doses  of  ten  to  forty  grains  three  times 
daily,  freely  diluted.  In  gouty  glycosuria  it  is  sometimes  very 
useful. 

An  objection  to  alkaline  treatment  is  the  general  depression 
which  is  apt  to  supervene  in  the  system  in  consequence.  Alkaline 
salts,  especially  those  of  potassium,  act  as  cardiac  depressants.2 
Hence,  it  is  well  to  reduce  the  larger  doses  necessary  at  the  outset 
of  acute  stages,  and  to  employ  smaller  ones  in  combination  with 
ammonium  salts.  To  prevent  the  depressant  effects  it  is  desir- 
able, in  some  cases,  to  combine  quinine  or  cinchona  bark  with 
them.  This  quino-alkaline  treatment  is  of  particular  value  in 
chronic  gout,  and  will  be  again  referred  to.  The  profession  is 
indebted  to  Garrod  for  this  excellent  combination. 

Sodium  salts  are  better  borne  for  a  long  continuance,  and  as 
existing  in  the  waters  of  Vichy  are  of  high  value  as  anti-gouty 
remedies. 

It  is  often  desirable  to   combine  several  alkalies  in  one  pre- 

1  The  good  effects  of  Bath  and  Contrexeville  waters  would  apparently  contradict 
this  opinion,  since  they  contain  carbonate  and  sulphate  of  calcium.  They  increase 
the  alkalinity  of  the  blood,  but  not  of  the  urine. 

2  Potassium  salts  tend  to  arrest  the  heart's  action  in  diastole,  to  inhibit  the  rhyth- 
mical action,  and  to  render  it  less  and  less  susceptible  to  the  effect  of  continuous 
faradization.  The  salts  of  ammonium  are  less  powerfully  depressing,  and  those  of 
sodium  least  so.     {Ringer.) 


DIETARY    IN    ACUTE    GOUT.  363 

scription,  as  potassium  and  sodium,  or  either  with  lithium  salts 
and  ammonium. 

Diluent  drinks  should  always  be  taken  during  a  course  of 
treatment  by  alkalies. 

I  have  treated  many  cases  of  acute  gout  with  alkalies  alone, 
and  have  often  been  well-satisfied  with  the  result.  Where  col- 
chicum  has  been  abused,  or  is  undesirable,  the  alkalies  may  be 
given  in  doses  of  from  fifteen  to  twenty-five  grains  every  four  or 
six  hours  for  two  or  three  days. 

Iodide  of  potassium  is  hardly  available  in  primary  or  early 
paroxysms,  but  is  of  much  service  in  various  phases  of  subacute 
and  chronic  gout,  and  in  gouty  cachexia. 

Atter  acute  attacks  of  arthritis,  it  is  a  good  practice  to  strap  or 
bandage  the  joints  for  some  time.  Subsequently,  gentle  friction, 
after  soapy  ablution  daily,  with  any  simple  liniment,  is  advisable ; 
and  if  deep-seated  pains  remain,  warm  pediluvia  at  night,  con- 
taining half  an  ounce  of  compound  tincture  of  iodine,  are  to  be 
recommended,  or  the  compound  mustard  liniment  may  be  used. 

Dietetic  Treatment  of  Acute  Gout. 

In  respect  of  the  diet  suitable  in  any  particular  case,  regard 
must  be  had  to  the  special  circumstances,  age,  and  habits  of  the 
patient.  The  dietary  for  a  sthenic  case  in  a  young  and  plethoric 
man  may  not  be  the  same  as  for  an  asthenic  case  in  an  elderly 
and  broken-down  man.  Hence,  there  must  be  variation  according 
to  circumstances. 

In  a  primary  paroxysm  in  an  over-fed  man,  it  is  important  to 
prescribe  a  sparing  diet,  consisting  chiefly  of  light  and  diluted 
nutriment.  Farinaceous  food,  bread  and  milk,  simple  rice,  tapioca, 
semolina,  or  sago  pudding,  weak  tea,  cocoa-nib "  infusion,  thin 
mutton  or  chicken  broth,  milk,  and  arrowroot  or  gruel  may  be 
given.  Jelly  and  all  gelatinous  foods  are  objectionable,  as  they 
tend  to  furnish  glycocine.  Alcoholics  in  all  forms  should  be  with- 
held, unless  specially  indicated.  Boiled  whiting  or  sole  may  be 
allowed  after  a  day  or  two  if  there  is  positive  hunger,  and  a  morsel 
of  mealy  potato.  Meat  and  nitrogenous  foods  generally  are  contra- 
indicated.  Without  doubt,  cases  of  the  kind  under  consideration 
do  best  on  the  diet  just  mentioned.  In  elderly  persons,  accus- 
tomed to  free  stimulation,  it  is  important  not  to  allow  the  patient 
to  lose  power,  and  the  dietary  may  be  improved  by  a  little  white 
meat,  chicken,  or  fish,  and  a  small  allowance  of  mature  brandy 
or  whisky,  well-diluted.      This  should  not  exceed  two  ounces  in 


364      TREATMENT    OF   THE    SEVERAL    VARIETIES    OF    GOUT. 

the  day,  unless  distinctly  called  for.  The  state  of  the  pulse  and 
of  the  heart's  action,  together  with  that  of  the  kidneys,  will  aid  in 
the  determination  as  to  the  quantity  of  stimulant  needed.  If  there 
is  more  than  a  cloud  of  albumen  in  the  urine,  it  will  be  well  to 
limit  alcohol  as  much  as  possible,  and  the  same  applies  to  any 
undue  pulse-tension. 

It  has  lately  become  a  fashion  to  give  port  wine  in  cases  of  acute 
gout.  I  am  sure  that  this  is  wrong,  and  a  practice  to  be  deprecated. 
It  may  please  the  patient,  but  it  is  a  mischievous  prescription. 
Without  question,  such  a  practice  may  be  sometimes  necessary 
and  very  useful,  but  it  must  be  reserved,  with  other  varieties  of 
treatment,  for  particular  cases.  In  any  case,  it  is  the  patient,  and 
not  the  disease,  that  is  to  be  treated,  and  no  routine  habits  are  safe 
at  the  bedside.  Within  the  domain  of  rational  therapeutics,  there 
can  be  no  fashion  in  this  or  in  any  other  plan  of  treatment. 

2.— Medicinal  and  other  Treatment  of  the  Gouty  in  the 
Intervals  between  the  Paroxysms. 

When  an  acute  attack  of  gout  has  passed  off,  there  commonly 
remains  some  general  debility,  although  the  patient  may  feel  in 
better  health  than  he  has  done  for  some  time  previously.  Much 
will  depend  on  the  treatment  during  the  fit,  and  still  more  on 
the  individual  habits  and  proclivities  of  the  patient,  in  respect  of 
the  future  conduct  of  the  case.  If  the  previous  habits  have  been 
bad  and  gout-inducing,  and  the  patient  be  possessed  of  sufficiently 
strong  will,  much  may  be  secured  if  a  better  manner  of  life  be 
followed.  Unfortunately,  in  most  cases,  by  the  time  gout  is 
overtly  manifested,  a  patient  has  fallen  into  routine  habits,  which 
he  is  commonly  averse  from  altering  to  any  material  extent. 
His  tastes  and  appetites  are  formed,  and  he  is  little  desirous  of 
being  dieted,  or  converted  into  a  valetudinarian.  So  much  the 
worse  for  him,  since  his  future  welfare  depends  on  a  life  guided 
by  rule.  The  balance  of  health  is  dependent  on  no  one  circum- 
stance, but  is  entirely  maintained  by  the  observance  of  many, 
often  small,  matters.  Hence,  to  treat  the  gouty  proclivity,  or 
state,  with  success,  demands  minute  attention  to  most  of  the 
points  which  concern  the  course  of  daily  and  nightly  life.  Inat- 
tention to  some  of  these  seemingly  trifling  matters  may  prevent 
the  full  measure  of  benefit  that  may  be  hoped  for,  and  often 
secured. 

The  main  lines  of  treatment  for  those  goutily  disposed  are 
directed  to  the  diminution  of  uric  acid  generally  in  the  system, 


TREATMENT  BETWEEN  PAROXYSMS.        365 

and  to  the  rapid  circulation  and  removal  of  any  excess,  stasis,  or 
deposition  of  that  which  is  formed.  In  addition  to  this,  attention 
must  be  paid  to  the  general  nutritive  processes,  and  in  particular 
to  the  evolution  of  nervous  energy.  Under  the  head  of  Preven- 
tive Treatment,  I  propose  to  discuss  these  points  more  at  length. 
The  management  of  the  patient  after  an  acute  paroxysm  now 
demands  attention.1  In  many  cases  it  will  he  found  necessary 
to  alter  existing  habits  of  life,  more  especially  in  regard  to  brain- 
work,  diet,  and  exercise.  After  earlier  attacks,  it  is  imperative 
to  insist  on  bodily  activity,  regular  hours  for  mental  work,  and 
strict  dietetic  regimen.  In  cases  occurring  early  in  life,  with 
strong  hereditary  proclivity,  it  may  be  important  to  forbid  the 
use  of  all  alcoholic  liquors.  No  routine  practice  can,  however, 
be  pursued  even  in  cases  of  this  class,  for  not  a  few  of  such 
patients  are  far  from  being  robust,  and  may  have  weak  hearts,  a 
feeble  circulation,  and  sluggish  nutritional  power.  If  there  be 
vigorous  circulation,  and  anything  approaching  hasmic  plethora, 
and  if  the  appetite  is  good,  abstention  from  alcoholic  drinks  may 
be  tried  for  a  year  or  two,  the  patient  being  kept  under  obser- 
vation. 

Later  in  life,  it  may  be  well  to  resume  the  use  of  a  little  wine. 
Early  hours  at  each  end  of  the  day  should  be  the  rule,  and  walk- 
ing exercise  or  equitation  regularly  practised.  The  patient  should 
walk  not  less  than  three  or  four  miles,  or  ride  not  less  than  an 
hour  daily.  The  ordinary  cold  hip-bath  should  be  taken,  in 
winter  with  the  chill  off,  followed  by  vigorous  towelling,  prompt 
dressing,  and  breakfast.  Some  exercise  should  be  taken  in  the 
forenoon,  and  any  occupation  followed  till  luncheon.  The  char- 
acter of  this  meal  must  vary  according  to  the  exercise,  brain-work, 
and  the  amount  of  food  eaten  at  breakfast.  If  the  latter  meal  is 
slender,  a  better  luncheon  is  necessary.  "Women,  as  a  rule,  eat 
most  heartily  at  midday,  and  men  make  a  better  breakfast  than 
the  former.  Butcher's  meat  should  be  taken  but  once  in  the 
day,  presumably  at  the  evening  meal.  No  wine  or  stimulant  is 
desirable  at  luncheon.  Occupation  and  exercise  should  be  carried 
on  in  the  after  part  of  the  day,  and  dinner  taken  not  too  late. 
No  food  is  requisite  after  the  latter  meal;  only  weak  tea, 
plain  water,  or  some  mineral  water  should  be  taken  two  hours 
aiterwards.  No  coffee  should  be  taken  at  night.  Not  less  than 
seven,  and  no  more  than  eight  hours  should  be  spent  in  bed. 
Curtailment  of  sleep  is  very  injurious  to  the  gouty,  and  excessive 

1  "The  absence  of  typical  attacks  of  gout  is  no  proof  that  the  gouty  process,  as 
such,  is  cured." — Ebstein,  op.  cit. 


366   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

indulgence  in  bed  is  equally  harmful.  Regular  habits  and  equa- 
bility of  life,  as  far  as  possible,  are  to  be  maintained.  With  the 
wealthy  and  well-to-do  there  will,  probably,  always  be  a  tempta- 
tion to  break  in  on  the  even  tenour  of  such  habits.  "  Exposure 
to  luxury  "  is  the  most  serious  and  malign  influence  to  be  com- 
bated. All  excess  is  surely  harmful  for  the  gouty,  whether  in 
harmless  or  pernicious  things.  Too  much  study  and  mental 
strain  are  about  as  bad  as  sheer  idleness  or  mental  vacuity ;  the 
morality  of  neither  can  be  justified.1  Ne  quid  nimis  must  be  the 
motto  of  a  gouty  man's  habits  of  life.  Moderation  in  all  things, 
in  work  and  play,  in  eating,  drinking,  and  in  exercise,  is  the 
key-note  of  the  physician's  instructions  to  a  goutily-disposed 
patient.  Any  break  in  the  equability  of  life  suitable  for  such  a 
patient  is  certain  to  carry  penalty  with  it,  and  to  induce  some 
degree  of  disturbance  of  health  which  it  may  take  long  to 
remove.  Great  care  is  necessary  in  exercising  restraint  at 
public  or  private  dinner-parties.  The  habitual  diner-out  is  very 
apt  to  develop  or  acquire  gout.  The  ordinary  fashionable 
dinner,  though  now,  happily,  more  refined  and  less  ponderous 
than  formerly,  is  a  terrible  ordeal  for  a  gouty  man.  If  well- 
advised  and  prudent,  he  can  but  pick  his  way  warily  through 
the  mSnu,  and  must  avoid  especially  excess  of  meats  and  wines, 
and  any  indulgence  in  the  sweet  courses.  If  any  indiscretion 
be  committed,  it  must  be  rigidly  atoned  for  afterwards,  even 
if  the  hesterna  vitia  of  the  dinner-table  do  not  compel  more 
strict  abstinence  for  some  days  subsequently.  Not  more  than 
one  such  dinner  in  a  week  can  be  safely  indulged  in ;  and  if  the 
claims  of  public  or  official  life  compel  greater  frequency  than  this 
at  certain  periods,  a  rigid  habit  of  extreme  abstinence  on  each 
occasion  should  be  forthwith  begun,  and  never  deviated  from. 

The  best  dietary  is,  in  truth,  that  which  is  most  suitable  for 
the  dyspeptic.  The  food  should  be  well  but  plainly  cooked.  It 
is  wise  to  avoid  all  things  boiled,  baked,  or  stewed.     Pastry  is 

1  The  effects  of  brain-work  are,  however,  not  always  harmful,  even  during  an  acute 
attack.  The  case  of  Lord  Palmerston  was  one  in  point.  One  of  the  traits  of  this 
remarkable  man  was  "  his  wonderful  power  of  mastering — I  might  call  it  ignoring — 
bodily  pain.  I  have  seen  him  under  a  fit  of  gout  which  would  have  sent  other  men 
groaning  to  their  couches,  continue  his  work  of  writing  or  reading  on  public  business 
almost  without  abatement,  amidst  the  chaos  of  papers  which  covered  the  floor  as  well 
as  the  tables  of  his  room.  To  Lord  Palmerston  work  was  itself  a  remedy.  The 
labour  he  loved  '  physicked  pain.'  No  anodyne  I  could  have  prescribed  would  have 
been  equally  effectual  in  allaying  it,  or,  as  I  may  better  say,  in  lessening  that  sense 
of  suffering  which  is  always  augmented  by  the  attention  of  the  mind  directed  to  it." 
— Recollections  of  Past  Life,  by  Sir  Henry  Holland,  Bart.,  M.D.,  p.  197.  London, 
1872. 


DIETARY    FOR    THE    GOUTY.  367 

bad.  All  fats  and  fatty  tissues  should  be  sparingly  used  when 
roasted  or  browned  ;  otherwise,  fats  are  not  unwholesome  for  the 
gouty.  Suet  and  bacon  fat  are  the  least  harmful.  Oily  fishes 
and  game  are  unsuitable.  Roasting  and  grilling  are  the  best 
methods  of  cooking.  White  fish  is  harmless  in  any  quantity 
likely  to  be  taken,  but  it  cannot  be  long-continued  instead  of 
butcher's  meat,  as  most  patients  tire  of  it.  Lean  meats,  in  modera- 
tion, are  not  hurtful,  but  should  be  taken  with  but  little  wine,  and 
plenty  of  diluents  subsequently.  Sweet-bread  and  thymus  gland 
of  the  calf,  liver,  ox-tongue,  chicken,  turkey,  and  tender  game 
birds  are  all  admissible,  the  skin  and  fat  of  the  latter  being  care- 
fully avoided,  that  of  the  duck  and  goose  being  especially  bad. 
Lightly  boiled  or  poached,  but  not  fried,  fresh  eggs  may  be 
taken.  Sauces  of  any  kind  are  not  admissible,  or  only  sparingly. 
Puddings  and  sweet  courses  should  be  eschewed,  and  a  small 
portion  of  savoury  omelette  may  replace  them  occasionally,  or  a 
morsel  of  not  over-ripe  cheese  with  toast  or  "  pulled  "  bread  may 
conclude  the  dinner. 

My  friend  Mr.  H.  W.  Jackson,  formerly  in  practice  at  Lewis- 
ham,  long  a  martyr  to  gout,  has  found  immunity  from  all  symp- 
toms by  adherence  to  the  following  dietary.  He  had  previously 
tried  every  method  of  treatment  and  every  variety  of  diet  un- 
availingly : — 

Dietary. 

A.M. 

8.15     .     .     .     10  oz.  hot  water. 

9.0      .     .     .     16  „    coffee  with  hot  milk. 

6  „    bread  and  butter  (six  drachms) ;  four  lumps  of 
loaf  sugar ;  salt. 

P.M. 

1.0       ...  Meat  (about  half  a  ration)  with  little  fat — no 

browned  fat ;  potatoes,  with  or  without  green 
vegetables ;  a  little  mustard,  if  any ;  no  pepper. 
1 1  oz.  cold  water,  freed  from  lime  by  boiling. 
5-0      ...     11  „    hot  water. 

6.0      .         .     16  „    tea,  with  pinch  of  soda  bicarbonate. 
6  „    cold  milk  in  the  tea. 

6  „    cold  milk  alone;  bread  and  butter  (six  drachms); 
toast  and  butter ;  loaf  sugar  (two  lumps) ;  a 
large  piece  of  cheese ;  salt. 
9.0       .     .     .     1 1  „    hot  water. 


93  oz.  total  of  fluids. 


A  larger  allowance  than  is  customary  of  pure  water  or  simple 
mineral  water  should  be  taken.  Some  persons  rarely  drink 
any  water  in  the  course  of  the  day.     Not  less  than  a  pint  of 


368   TREATMENT  OF  THE  SEVERAL  VARIETIES  OP  GOUT. 

pure  water  should  be  added  to  the  ordinary  allowance  taken,  and 
it  may  be  drunk  hot  after  meals.  I  think  it  is  a  good  plan 
to  take  half  a  pint  of  water  in  slow  sippings  in  the  hour  before 
retiring  to  bed.  The  common  habit  of  adding  some  spirit  to  this 
is  bad,  and,  even  if  desirable,  must  be  a  matter  for  the  physician 
to  decide.  For  younger  persons  there  can  be  no  question  that 
this  is  a  harmful  practice. 

Tobacco-smoking  in  strict  moderation,  at  a  short  interval  after 
meals,  I  do  not  believe  to  be  unwholesome  for  the  goutily  dis- 
posed, provided  it  causes  no  dyspepsia  and  disagrees  in  no 
obvious  manner.  The  least  excess  is  harmful.  Cigarette-smok- 
ing is  the  worst  and  most  insidious  form  of  the  practice. 

To  regularity  of  daily  habits  and  general  equability  of  life, 
must  be  added  the  practice  of  chastity.  Sir  Henry  Halford 
quotes,  and  lays  stress  upon,  Pliny's  word  for  this  special  virtue 
— "  sanctitas."  x  It  is  certain  that  sexual  excess  is  provocative  of 
gouty  paroxysms  and  manifestations,  and  I  feel  sure  that  such 
indulgence  early  in  life,  by  its  general  enervating  influence,  is 
potent  not  only  in  determining  early  and  severe  attacks,  but  also  in 
the  premature  induction  of  gouty  cachexia.  As  may  be  well-under- 
stood, nothing  is  more  harmful  for  those  predisposed  to  this  malady 
than  combined  and  inordinate  indulgence  in  venery  and  wine. 

Arthritic  Obesity. — Ebstein  is  of  opinion  that  a  tendency  to 
obesity  is  an  untoward  symptom  in  those  of  gouty  habit,  and 
believes  that  fatty  deposit  affords  a  favourable  soil  for  the  dis- 
ease ;  further,  that  by  checking  this  tendency  we  may  remove  the 
most  active  exciting  cause  of  gouty  symptoms.  The  dietary 
recommended  by  him  to  prevent  such  obesity  includes  meat 
and  fat,  and  reduces  to  a  minimum  carbo-hydrates.  Thus,  he 
forbids  sugar,  pastry,  potatoes,  and  beer.  His  view  is  that  carbo- 
hydrates protect  albumen  from  destruction,  and  that  the  portion 
of  the  latter  which  is  not  taken  in,  or  metabolically  disposed  of, 
is  added  as  fat  to  the  system.  Fats  also  protect  albumen  from 
destruction,  but  in  far  less  degree  than  other  carbo-hydrates,  and 
that  part  which  is  decomposed  with  a  corresponding  use  of  fat 
is  transformed  completely,  and  is  not  stored  up  in  the  body  in  an 
intermediate  state  as  fat. 

I  am  not  prepared  to  agree  with  the  opinion  that  there  is  any 
special  danger  for  the  gouty,  more,  that  is,  than  for  other  persons, 
in  an  obese  tendency,  unless  it  be  decidedly  manifested.  It  is, 
perhaps,  a  less  common  deviation  in  England  than  in  Germany. 

1  "  Pedum  dolorem  fregit  abstinentia  et  sanctitate." 


ARTHRITIC    OBESITY.  369 

The  tendency  to  gouty  glycosuria  is  recognized  in  this  connection. 
As  to  the  utility  of  the  dietary  recommended  by  Ebstein,  I  am  in 
full  agreement.  Fat  in  any  form  readily  digested  is  good  for  most 
gouty  patients,  but  there  are  many  who  cannot,  and  will  not,  take 
it  save  in  the  form  of  fresh  butter  or  bacon.  With  respect  to 
beer,  the  noxious  principle  is  probably  rather  to  be  found  in  its 
free  acid  than  in  its  carbo-hydrates.  Both  together,  however,  are 
as  bad  as  can  well  be  conceived. 

The  treatment  of  arthritic  obesity  is  hardly  amenable  to  other 
measures  than  those  which  are  commonly  recognized  as  useful  in 
other  forms  of  polysarcia.  Where  this  peculiarity  of  nutrition  is 
early  manifested,  it  is  important  to  secure  active  habits  of  life,  and 
amidst  rural  surroundings,  if  possible.  Exercise,  riding  on  horse- 
back, and  open-air  life  are  all  advisable.  The  dietary  should 
consist  of  fish  and  butcher's  meat  in  fair  proportion,  with  fat  in 
moderation.  Hydro-carbonaceous  matters  should  be  limited,  espe- 
cially too  great  indulgence  in  bread  and  amylaceous  food.  Sugar 
must  be  largely  abstained  from.  Liquids  should  be  restricted  to 
absolute  requirements.  Some  form  of  alcohol  is  commonly  advis- 
able (red  Bordeaux  wine  with  a  little  water  is  the  best  form 
to  employ),  and  should  be  taken  once  a  day  with  the  principal 
meal.  Holiday  periods  should  be  passed  in  alpine  or  sub-alpine 
regions,  with  regular  and  active  exercise,  and  any  games  that  can 
be  played  be  assiduously  cultivated.  In  the  case  of  adults,  resort  to 
the  Spas  of  Marienbad  and  Carlsbad  for  several  successive  seasons 
is  advisable. 

3.— Treatment  of  Chronic  and  Irregular  Gout. 

Evidence  is  not  wanting  to  prove  that,  if  the  victims  of  gout 
and  gouty  states  are  not  adequately  treated,  the  disease  is  apt  to 
make  mischievous  progress,  to  lead  to  crippling  and  the  onset  of 
gouty  cachexia  with  wide-spread  textural  degenerations.  Hence, 
not  only  are  acute  fits  to  be  carefully  treated,  and  the  general 
health  restored,  as  far  as  possible,  in  the  intervals,  but  all  indi- 
cations of  goutiness  are  to  be  met  as  they  arise.  Successful 
management  of  the  multiform  phases  assumed  by  the  malady 
demands  accurate  recognition  of  the  gouty  element  always  and 
everywhere,  and  a  large  experience  in  clinical  medicine. 

The  general  principles  of  treatment  in  chronic  gout  relate  more 
particularly  to  the  condition  of  the  blood,  of  the  nervous  system, 
and  of  the  general  textural  nutrition.  All  measures,  therefore, 
which  tend  to  maintain  the  best  bodily  health  will  be  favourable 

2   A 


370      TREATMENT    OF    THE    SEVEKAL    VARIETIES    OF   GOUT. 

to  the  patient,  and  render  him  as  little  vulnerable  as  may  be  to 
the  various  assaults  of  the  disease.  The  better  the  constitution, 
the  less  mischievous  the  gout.  The  malign  combinations  of  dia- 
thetic states  in  any  individual  must  be  especially  taken  note  of. 
Activity  of  habits  must  be  fostered.  Indulgences  and  ease-taking 
must  be  resisted.  Exercise  in  all  forms  is  to  be  practised.  A 
good  action  of  the  skin  and  a  vigorous  circulation  must  be  main- 
tained. Too  much  sedentary  and  town-life  should  be  avoided. 
Equable  brain  and  muscular  energy  are  desirable.  Mental  and 
bodily  depression  from  any  causes  are  harmful.  Cheerful  sur- 
roundings should  be  sought,  and  mental  irritability  and  outbursts 
of  temper  should  be  restrained.  No  violent  change  in  any  whole- 
some habit  of  life  should  be  permitted. 

Hence  there  is  much  to  be  accomplished  before  any  special 
medication  is  resorted  to,  and  the  patient  must  be  impressed  with 
this,  and  not  be  encouraged  to  rely  on  physic  alone  for  relief  from 
his  varied  ailments.  The  belief  that  the  physician  can  conjure 
away  their  troubles  with  "  something  in  a  bottle  "  is,  unfortunately, 
not  confined  to  patients  of  the  humbler  classes,  and  a  better  phi- 
losophy than  this  has  to  be  expounded  daily  to  those  who  should 
know  better.  Any  who  fail  in  this  duty  to  their  patients  will  as 
certainly  often  fail  to  afford  all  the  relief  that  is  rightly  procur- 
able. Under  suitable  treatment,  applied  to  meet  all  the  require- 
ments of  individual  cases,  long  immunity  from  attacks  of  gout 
may  be  secured,  and  the  paroxysms  may  be  reduced  in  intensity. 

The  tendency  to  urichgemia  and  localized  deposits  of  urates  is 
best  medicinally  treated  by  courses  of  alkaline  remedies  given  at 
intervals,  together  with  occasional  aperients  containing  mercury 
and  colchicum,  or  with  a  hepatic  stimulant  such  as  euonymin. 
Lithium  salts  are  useful,  and  may  be  taken  in  the  form  of  lithia 
water.  Where  a  saline  aperient  is  advisable,  crystallized  Carls- 
bad, or  Homburg,  salts  may  be  taken  in  doses  of  two  drachms  in 
eight  ounces  of  hot  water  before  breakfast.  Any  of  the  "  bitter  " 
waters  act  well,  such  as  Hunyadi  Janos,  Friedrichshall,  Piillna, 
or  Rubinat  in  appropriate  doses.  The  disorder  of  the  liver 
associated  with  too  free  production  of  uric  acid,  or  induced  by 
storage  therein  of  that  acid,  is  well-treated  by  these  salines 
taken  for  some  mornings  in  succession,  and  their  efficacy  is 
largely  due  to  the  sodium  and  magnesium  sulphates  contained 
in  them.  A  larger  amount  of  water-drinking  than  is  customary 
is  useful  in  most  cases  of  chronic  gout.  For  subacute  attacks  of 
articular  inflammation,  colchicum  may  be  advantageously  used  in 
small  doses.      For  many  phases  of  chronic  gout  in  and  around 


TREATMENT  OF  CHRONIC  GOUT.  37 1 

joints,  and  to  keep  in  chock  degenerative  processes  in  many 
tissues,  I  believe  the  iodides  to  be  of  much  value.  The  sodium, 
lithium,  potassium,  and  ammonium  salts  may  all  be  used.  They 
tend  to  alleviate  pain  in  many  situations.  Their  action  is  some- 
times depressing,  and  this  may  be  prevented  by  combining  them 
with  cinchona  bark  or  with  quinine  and  nux  vomica ;  or  tincture 
of  iodine  may  be  given  with  ammonium  chloride  and  spirit  of 
chloroform.1  I  have  found  citrate  of  potassium,  iodide  of  lithium, 
and  nux  vomica  a  useful  prescription.  Three  or  five  grains  is  a 
dose  of  the  lithium  iodide.  Diluents  should  be  freely  used  when 
these  salts  are  prescribed,  and  I  know  no  better  one  than  a  pint 
(taken  daily)  of  the  compound  decoction  of  sarsaparilla  or  of  hemi- 
desmus,  especially,  if  the  patient  be  frail  and  poorly  nourished. 
Smaller  doses  of  the  latter  drugs  are,  I  believe,  of  no  avail  what- 
ever. Their  value  is  only  seen  when  used  as  "  diet  drinks." 
From  three  to  five  grains  of  potassium,  lithium,  or  sodium  iodide 
is  a  sufficient  dose. 

Cinchona  bark  and  quinine  are  very  useful  in  chronic  gout, 
promoting  better  digestive  and  nervous  power,  and  nux  vomica 
and  strychnia  are  also  of  high  value.  Quinine  may  often  be 
advantageously  given  with,  bicarbonate  or  with,  iodide  of  potassium 
in  from  two  to  five  grain  doses.  Guaiacum  is  in  repute  in  cases 
where  the  circulation  is  languid,  and  in  atonic  forms  of  gout.  It 
may  be  combined  with,  cinchona,  colchicum,  and  with  iodides. 
The  great  objection  to  it  is  its  unpleasant  taste.  I  believe  it  to 
be  of  sufficient  value  to  warrant  the  endurance  of  this  distasteful 
quality.  In  the  foirni  of  lithium  guaiacate,  the  effects  of  guaiacic 
acid  may  be  secured  in  pill,  two  to  five  grains  being  tlie  dose, 
made  up  with  glycerine  and  water,  and  administered  twice  or 
thrice  in  the  day.  Guaiacum  may  be  taken  with  benefit  over 
long  periods,  and  it  is  often  sufficiently  aperient  to  be  helpful  in 
many  cases.  Garrod  highly  recommends  a  powder  composed  of 
the  following  ingredients,  and  I  know  that  it  is  valuable : — 

R  Pulv.  Resinse  Guaiaci  ovi.,  Pulv.  Cinchonse  Flavse  5i.,  Ammonii  Carbonatis  5ij., 
Potassii  (vel  Lithii)  citratis  3ij.,  Potassii  Iodidi  3i.,  Pulv.  Cormi  Colchici  3i-  M.  ut 
fiat  Pulvis.  Sig.  Forty  grains  for  a  dose  in  a  wine-glassful  of  peppermint  water,  to 
be  taken  once  a  day,  continuously  or  in  alternate  weeks. 

This  combination  smacks  of  polypharmacy,  and  may,  therefore, 
shock  the  therapeuto-purists  of  the  present  day.  In  reply  to 
any  objections  on  this  score,  I  would  affirm  that  our  business,  as 

1  Dr.   Mortimer  Granville  has  especially  recommended  the  employment  of   free 
odine  in  gout. 


3J2       TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

physicians,  is  to  cure  our  patients,  and  that  our  duty  is  to  use 
remedies  in  any  fashion  which  will  best  secure  that  object. 

I  think  it  is  not  improbable  that  both  alkalies  and  iodides 
help  to  prevent  degenerative  processes  in  various  tissues,  and  so 
stave  off  the  worst  forms  of  pulmonary,  cardiac,  vascular,  and 
renal  disorders  so  commonly  associated  with  gout. 

Benzoates  of  sodium,  ammonium,  and  lithium  have  been  em- 
ployed in  the  treatment  of  chronic  gout  during  the  last  twenty  years 
with  a  varying  degree  of  success.  Garrod  has  extolled  them,  but 
other  observers  are  less  enthusiastic  as  to  their  merits.  Benzoic 
acid  is  excreted  by  the  kidneys,  after  uniting  there  with  glycocine, 
or  its  antecedent,  in  the  form  of  hippuric  acid,  thus  preventing 
formation  of  uric  acid.  It  is  especially  to  be  noted  that  benzoic 
acid  contains  no  nitrogen,  and  while  undergoing  transformation 
in  the  system  into  hippuric  acid  it  incorporates  that  element. 
According  to  Dr.  Noel  Paton,  benzoate  of  sodium  diminishes 
secretion  of  uric  acid.  Benzoate  of  lithium  I  have  frequently 
prescribed  in  chronic  gout,  and  sometimes  with  benefit.  I  often 
combine  it  with  tincture  of  nux  vomica.  The  dose  is  from  eight 
grains  to  half  a  drachm.  The  benzoates  may  be  combined  advan- 
tageously with  phosphate  and  carbonate  of  sodium,  as  recom- 
mended by  the  late  Dr.  Golding  Bird. 

From  time  to  time  haematic  medicines  are  called  for  in  the 
treatment  of  chronic  gout.  Where  anaemia,  cardiac  debility,  or 
albuminuria  is  present,  the  value  of  iron  as  a  remedy  naturally 
occurs  to  the  physician.  This  is  found  to  disagree  in  many  cases, 
and  to  induce  recurrence  of  gouty  attacks.  It  has  been  found 
to  check  the  elimination  of  uric  acid.  Small  doses  are,  how- 
ever, often  well  borne,  especially  of  the  non-astringent  prepara- 
tions. Three  or  four  grains  of  reduced  iron  or  of  the  ammonio- 
citrate,  tartarated,  or  carbonate  of  iron  may  be  given.  The 
ammonio-citrate  may  be  prescribed  with  a  few  ounces  of  Nassau 
Selters  water ;  or  any  chalybeate  water,  such  as  that  of  Spa,  St. 
Moritz,  Pyrmont,  or  Tunbridge  Wells,  may  be  taken  in  small 
quantities.  Some  saline  or  other  aperient  is  especially  necessary 
for  the  gouty  while  taking  a  course  of  iron,  and  may  prevent 
headache  and  other  disturbance  as  consequences  of  it. 

If  iron  disagrees,  it  is  not  easy  to  find  a  substitute.1  Dr. 
Munk  informs  me  that  he  sometimes  prescribes  manganesium 
salts  in  such  cases,  believing  that  they  act  as  tonic  and  haematic 

1  Dr.  Haig  found  that  iron  caused  retention  of  uric  acid  in  the  system  after 
twenty-four  hours  had  elapsed.  Urate  of  iron  is  quite  insoluble,  and  so  is  urate  of 
lead. 


IRON.      MANGANESE.       ARSENIC.  373 

remedies.  Dr.  Haig,  at  my  suggestion,  kindly  undertook  to 
observe  the  influence  of  manganesium  on  uric  acid  excretion,  and 
lie  reports  that  it  acts  much  in  the  same  way  as  iron  and  lead. 
When  first  taken,  it  causes  retention  of  uric  acid  with  pricking 
pains  in  the  joints  ;  but  later  on,  about  the  second  or  third  day, 
it  causes  very  decided  intestinal  irritation,  and  the  results  of  this 
(fall  of  urea  and  acidity)  overcome  its  primary  retentive  action, 
and  cause  increased  excretion  of  uric  acid.  He  took  the  sulphate, 
and  afterwards  the  precipitated  oxyde,  each  in  doses  of  ten  grains 
three  times  a  day.  Retention  of  uric  acid  and  joint-pains  were 
most  marked  with  the  sulphate,  but  the  oxyde  also  caused  them. 
He  remarks : — "  I  should  expect  that,  given  in  gout,  they  would 
slightly  increase  the  pains  at  first,  and  then,  when  intestinal 
irritation  and  falling  acidity  caused  plus  excretion  of  uric  acid, 
they  would  relieve  them ;  this  being,  as  I  have  suggested,  the 
way  in  which  colchicum  acts." 

Clinical  experience  must,  however,  be  the  ultimate  appeal  as 
to  the  real  value  of  any  drug,  and  I  conceive  that  salts  of  man- 
ganese may  prove  useful  as  haematics  in  doses  smaller  than  are 
needed  to  irritate  the  bowels.  There  is  evidence  of  their  action 
as  emmenagogues  in  cases  where  iron  is  commonly  useful  in 
improving  the  quality  of  the  blood,  and  1  see  no  reason  why  they 
should  not  be  employed  in  chronic  gout.  For  each  part  of  iron 
in  the  blood  there  is  about  one-twentieth  of  manganese,  and  the 
latter  is  contained  in  potatoes  and  many  other  kinds  of  food. 
Three  to  ten  grains  of  the  sulphate  or  of  the  precipitated  oxyde 
may  be  prescribed  for  a  dose.  Tabloids,  containing  two  grains 
of  the  latter,  are  available. 

Arsenic  is,  perhaps,  the  best  substitute  for  chalybeate  treat- 
ment. This  drug  has,  without  doubt,  a  powerful  effect  for  good 
in  a  large  number  of  ailments  connected  with  the  arthritic  habit 
of  body.  As  a  nutrient  and  nervine  tonic,  and  as  a  haematic 
remedy,  it  has  a  high  value.  It  is  of  particular  use  in  the 
neurosal  condition  associated  with  gout,  and  also  in  cases  of 
cardiac  debility  and  albuminuria  met  with  in  gout  and  its 
cachexia.  It  may  be  combined  with  alkalies  or  with  iron,  and 
beneficially  given  over  long  periods  with  short  intermissions. 
The  following  formulas  I  have  found  very  serviceable : — 

R  Tinct.  Ferri  Perchloridi  f3iss.,  Liq.  Arsenici  Hydrochlorici  f3ss.,  Liq.  Strychninse 
Hydrochloratis  f3ss.,  Syrupi  Tolutani  f5vi.,  Aquam  Destillatam  ad  fgviii.  M.  ut 
fiat  Mistura.     An  eighth  part  for  a  dose  twice  daily  after  the  principal  meals. 

R.  Potassii  Bicarbonatis,  Sodii  Bicarbonatis,  aa.  gr.lxxx.,  Liq.  Sodii  Arseniatis 
f3ss.,  Tinct.  Nucis  Vomicae  f3iss.,  Aquam  Chloroformi  ad  fgviii.  M.  ut  fiat  Mistura. 
An  eighth  part  to  be  taken  twice  daily  two  hours  after  the  principal  meals. 


374      TREATMENT    OF    THE   SEVERAL    VARIETIES    OF   GOUT. 

R  Ferri  et  Ammonii  Citratis  gr.xl.,  Potassii  Bicarbonatis  3ij-j  Liq.  Arsenicalis 
f3ss.,  Infusi  Calumbse,  Aqua  Mentb.  Pip.  aa.  f§iv.  M.  ut  fiat  Mistura.  An  eighth 
part  to  be  taken  twice  daily  between  meals. 

Iron  may  be  combined  with  iodine  in  cases  where  the  latter  is 
thought  desirable.  I  prefer  the  mixture  of  tartarated  iron  with 
potassium  iodide  to  the  officinal  syrup  of  iodide  of  iron. 

Sulphate  of  nickel  has  been  employed  as  a  tonic,  but  I  have 
no  experience  of  its  use. 

If  the  action  of  the  bowels  is  defective  in  cases  of  chronic 
gout,  it  is  best  to  avoid  too  frequent  resort  to  aperients  of  a 
depressing  character.  In  plethoric  persons  who  live  well,  and 
take  insufficient  bodily  exercise,  great  advantage  will  be  gained 
by  a  periodical  aperient  containing  mercury,  taken  over-night  at 
intervals  of  three  weeks,  followed  by  a  dose  of  any  natural  bitter 
water  the  next  morning.  In  cases  marked  by  general  asthenia, 
a  simple  "  dinner-pill  "  will  commonly  suffice,  containing  aloes, 
nux  vomica,  and  extract  of  anthemis.  Cascara  sagrada,  or  small 
enemata  of  glycerine  (f3i.— f5ij.)  will  be  found  serviceable  in  such 
cases.  Small  doses  of  castor  oil  are  of  use,  taken  at  night,  or 
equal  parts  of  this  and  oil  of  sweet  almonds.  A  pill  taken  at 
bed-time  containing  four  grains  of  compound  rhubarb  pill  with 
one  of  quinine,  will  sometimes  avail  to  secure  a  return  of  natural 
daily  evacuations.  The  objection  to  strong  purgings  so  commonly 
mentioned  by  the  old  authors  on  gout  has  been  shown  by  Dr. 
Munk  to  have  arisen,  probably,  from  the  fact  that  in  Sydenham's 
time,  and  for  long  afterwards,  purgatives  were  too  commonly 
violent  and  irritating,  and  very  different  from  those  employed  in 
the  present  day. 

4.— Local  Treatment  of  the  Joints  in  Chronic  Gouty 
Arthritis.— Treatment  of  Tophi. 

In  connexion  with  repeated  attacks  of  gout  in  any  joint, 
certain  textural  changes  are  apt  to  remain,  and  lead  to  discomfort 
and  deformities.  The  oedema,  which  soon  passes  off  in  acute 
and  early  attacks,  may  tend  in  later  and  subacute  paroxysms 
to  linger.  This  is  found  in  both  upper  and  lower  limbs,  perhaps 
more  so,  and  naturally,  in  the  latter.  It  may  be  aided  in  dis- 
persion by  frictions  and  moderate  pressure ;  liniment  of  soap  or 
of  camphor  may  be  rubbed  in,  and  domet  bandages  skilfully 
applied.  Elastic  stockings,  and  suitable  position,  are  sometimes 
necessary  for  the  lower  limbs.     Friction  and  electrical  stimulation 


TREATMENT   OF   JOINTS    IN    CHRONIC   GOUT.  375 

are  of  great  value  in  many  of  the  local  troubles  of  chronic  gout, 
and  will  be  subsequently  referred  to. 

Stiffness  is  a  common  result  after  uratic  arthritis,  and  may  be 
present  in  all  degrees,  from  the  slightest  up  to  firm  synostosis 
(true  ankylosis).  Partial  or  false  ankylosis  is  commoner  than 
that  which  is  true,  and  may  be  due  to  fibroid  thickening,  bony 
outgrowth,  and  to  uratic  incrustation  of  bones,  tendons,  or  liga- 
ments, or  even  to  all  of  these  combined.  Friction  is  very  proper 
in  such  cases,  and  some  stimulating  liniments  may  be  used  with 
benefit.  One  of  the  best  is  the  linimentum  sinapis  compositum, 
recommended  by  Garrod.  Passive  movements  and  friction,  so 
far  as  they  can  be  borne  without  pain,  are  to  be  employed. 
Tincture  of  iodine  and  small  strips  of  cantharides  plaster  are  of 
great  use  in  restoring  movement  and  dispersing  deformities.  The 
latter  is  to  be  applied  only  as  a"  flying  "  blister,  and  may  be 
repeated  several  nights  in  succession.  Menthol,1  oil  of  pepper- 
mint, and  cocaine  2  are  local  remedies  of  value,  if  there  be  much 
pain  in  connection  with  stiffened  joints,  also  camphor  and  chloral- 
hydrate  in  mixture.  Proper  support  for  the  arms  and  the  gout- 
stool  are  necessary  in  these  cases. 

Where  large  uratic  incrustations  and  deposits  occur,  I  would 
enforce  caution  in  undertaking  any  kind  of  treatment.  It  is  best 
not  to  be  too  active  in  endeavours  to  remove  these.  Tophi  in  the 
ears  and  other  superficial  parts  sometimes  drop  out  spontaneously, 
or  are  picked  out  by  the  patient.  Larger  masses  are  apt  to  burst 
of  themselves,  a  small  diffluent  collection  usually  pointing  in  some 
direction  previously.  Bread-poultices  may  be  applied,  with  un- 
guentum  resinee  spread  over  them.  Compresses  wetted  with  alka- 
line solutions  are  also  available,  in  which  bicarbonate  of  potassium, 
carbonate  of  lithium,  and  iodide  of  potassium  are  the  active  sol- 
vent and  dispersing  agents.  Five  grains  of  any  of  these  salts  in 
an  ounce  of  distilled  or  rose  water  is  sufficient. 

All  interference  with  the  knife  is  to  be  strongly  deprecated  in 
such  tophi  as  have  deep  connections.  I  have  known  serious  mis- 
chief follow  a  cutting  operation.  In  Fig.  12,  p.  80,  is  depicted 
the  linear  scar  of  an  incision  made  into  a  large  tophus,  which  was 
sufficiently  inviting,  though  not  at  my  instigation,  to  a  surgeon's 
scalpel.  The  subject  of  it  had  a  narrow  escape  for  his  life  in  con- 
sequence of  erysipelas.  When  the  uratic  discharge  is  scanty,  it 
is  also  bad  practice  to  try  and  press  out  more  than  flows  spon- 

1  ft  Menthol  3iss.,  Linimenti  Saponis  §iij.     M.  ft.  Linimentum. 

2  ft  Cocaine  3ss.,  Acidi  Borici  gr.x.,  Aq.  Destillatam  ad  fij.     Solve  et  M.  ut  fiat 
Lotio.     To  be  applied  on  lint. 


376   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

taneously.     No  probing  or  use  of  caustics  is  justifiable.     Erysipelas 
and  gangrene  may  follow  meddlesome  therapeutic  efforts. 

Sometimes,  a  bursal  sac  containing  tophi  proceeds  to  suppura- 
tion, as  over  the  olecranon,  and  in  this  case  we  have  to  deal  with 
an  abscess  incidentally  containing  gouty  deposits.  The  ordinary 
rules  of  surgery  must,  of  course,  be  followed,  and  the  matter  let 
out.      These  cases  usually  heal  well. 

The  action  of  the  skin  is  to  be  maintained  by  warm  clothing 
and  regular  exercise.  The  Turkish  bath  is  of  value  in  averting 
gout,  and  when  it  agrees  and  is  taken  with  proper  precautions,  it 
may  be  recommended.  I  should  not  advise  its  employment  in 
patients  over  fifty  years  of  age,  and,  in  any  case,  not  more  fre- 
quently than  three  times  in  the  course  of  a  month.  It  is,  how- 
ever, a  remedial  and  preventive  measure  for  robust  persons  whose 
gouty  manifestations  are  of  sthenic  character.  Where  signs  of 
cardiac,  vascular,  and  renal  degeneration  are  present,  the  use  of 
Turkish  baths  is  to  be  forbidden. 

Warm  baths  are,  however,  of  great  use,  and  may  be  employed 
twice  a  week.  I  shall  reserve  what  I  have  to  remark  on  the  use 
of  baths  and  mineral  waters  in  the  treatment  of  gout  for  another 
chapter. 

Warm  pediluvia  are  sometimes  found  to  be  soothing  in  cases 
of  lingering  gout  in  the  feet.  One  experienced  sufferer  told  me 
of  the  great  relief  he  obtained  from  a  foot-bath  containing  an 
ounce  of  carbonate  of  potash  and  half  an  ounce  colchicum  wine 
in  three  pints  of  water.  In  his  case  the  application  of  six  leeches 
to  a  great  toe-joint  had  failed  previously  to  afford  any  relief. 

5.— Treatment  of  Retroeedent  and  Incomplete  Gout. 

From  a  clinical  point  of  view  retrocedency  of  gouty  processes 
may  be  best  regarded  as  occurring  both  suddenly  and  acutely,  and 
also  in  a  quieter  and  more  abiding  form  as  substituted  or  irregular 
manifestations. 

(i.)  Sudden  retrocedence  is  commonly  a  violent  process,  and 
sometimes,  as  in  the  case  of  metastasis  to  the  brain,  heart,  or 
stomach,  sufficiently  alarming  both  to  the  patient  and  the  prac- 
titioner. It  is  important  to  recognize  the  gouty  element  in  each 
instance,  if  treatment  is  to  be  efficient. 

The  therapeutical  indication  is  to  afford  relief  to  the  oppressed 
organs  by  the  reinduction  of  a  regular  and  articular  paroxysm. 
The  most  valuable  means  of  promoting  this  is  the  hot  pediluvium 
with  mustard-flour  in  the  proportion  of  half  an   ounce  to   each 


TREATMENT  OF  RETROCEDENT  GOUT.        377 

gallon  of  water.  Where  this  is  undesirable,  mustard-poultices  may- 
be placed  round  each  great  toe  and  instep.  The  urgent  symptoms 
are  best  relieved  by  some  diffusible  stimulant,  such  as  asther  or 
brandy,  with  or  without  opium,  according  to  the  degree  of  renal 
adequacy. 

The  two  varieties  of  gastric  gout  demand  different  treatment. 
In  the  milder  form  occurring  in  chronic  gout,  without  pyrexia, 
where  the  pain  is  relieved  by  pressure,  and  there  is  no  vomiting,  but 
rather  cramp  and  sinking  sensation,  emetic  action  may  be  encour- 
aged by  draughts  of  warm  water,  containing  a  little  alcohol.  Sina- 
pisms should  be  placed  over  the  epigastrium,  and  applied  to  the 
joints  that  have  previously  suffered.  In  the  severe  inflammatory 
form,  opium  is  called  for,  and  stimulants  must  be  withheld. 
Leeches  or  a  blister  should  be  applied  to  the  epigastrium,  and 
effervescing  draughts  with  potass  and  hydrocyanic  acid  be  given. 
The  gout  should  be  recalled  to  the  joints.  Moderate  purgation 
with  calomel  and  compound  colocynth  pill  is  commonly  advisable. 

Sinapisms  to  the  epigastrium  are  useful  in  cases  of  metastasis 
to  the  heart  or  stomach.  If  much  flatulency  is  present,  as  is 
often  the  case  in  a  gastric  or  cardiac  crisis,  asther,  with  spirit 
of  cajuput  and  camphor  or  peppermint  water,  is  of  value,  and, 
sometimes,  stimulants  are  needed  in  large  quantity,  owing  to 
collapse  and  profound  cardiac  failure.  In  a  plethoric  patient  with 
gouty  cerebral  metastatic  crisis,  where  stupor  and  mental  con- 
fusion prevail,  or  coma  supervenes,  and  where  the  pulse  is  unduly 
firm,  vengesection  may  be  advantageously  practised,  and  from  ten  to 
twenty  ounces  of  blood  be  let. 

There  is  need  for  care  in  diet  for  some  time  subsequently, 
and  no  solid  food  should  be  given  for  several  days. 

With  the  return  of  regular  articular  gout,  there  is  commonly 
complete  relief  to  all  the  urgent  symptoms.  If  gastritis  or 
enteritis  is  not  completely  relieved,  appropriate  treatment  for 
these  conditions  must  be  applied,  liquid  food  being  given  in  small 
quantities,  and,  as  medicine,  sodium  bicarbonate  with  bismuth  and 
dilute  hydrocyanic  acid. 

(2.)  In  the  second  class  of  gouty  metastases,  the  symptoms  are 
not  urgent  or  violent.  The  patient  suffers  from  incomplete  or 
misplaced  gout.  This  may  follow  the  suppression  of  some  skin- 
eruption,  or  result  from  any  cause  capable  of  inducing  gout  in  a 
predisposed  subject,  whose  health  is  less  vigorous  than  formerly. 
It  has  been  shown  that  atonic  gout  is  the  form  most  likely  to  be 
aberrant  or  retrocedent.  The  line  of  treatment  to  be  pursued  is 
that  of  promoting  a  regular  gouty  articular  process,  and  the  same 


37 '8       TREATMENT    OF    THE    SEVERAL   VARIETIES    OF    GOUT. 

method  must  be  followed  in  cases  of  suppressed  gout.  Any  skin- 
disease  is  best  neglected,  or  it  may  even  need  to  be  recalled  into 
activity  by  some  mild  irritant.  Patches  of  dry  eczema  on  the 
limbs,  when  not  active,  or  when  subdued  by  treatment,  are  some- 
times found  to  alternate  with  some  renal  difficulty ;  while  those 
on  the  trunk  may  subside  and  induce  pulmonary  trouble,  such  as 
bronchitis  or  asthma. 

Where  a  gouty  paroxysm  is  felt  to  be  imminent  and  yet  does 
not  come  on,  an  articular  attack  may  fairly  be  encouraged,  if  the 
vexatious  symptoms  fail  to  yield  to  appropriate  general  treatment 
by  medicine  and  by  diet.  This  may  sometimes  be  promptly 
accomplished  by  the  prescription  of  a  pint  of  champagne  and  a 
subsequent  hot  pediluvium.  Other  wines,  such  as  port  or  Madeira, 
are  effectual  for  this  purpose,  but  are  less  swift  in  operation. 
The  mode  of  action  here  I  conceive  to  be  the  reduction  of  the  alka- 
linity of  the  blood  to  a  point  whence  some  decided  uratic  preci- 
pitation is  rendered  certain,  and  the  irritant  to  the  extremities 
determines  the  localization  of  the  gouty  outburst. 

The  treatment  subsequently  is  that  for  ordinary  gout.  Colchicum 
is  commonly  effectual  in  such  cases,  and  need  not  be  given  in 
large  doses,  but  rather  in  small  ones  over  an  extended  period. 
It  is  important  in  all  cases  of  gout  with  retrocedent  tendency  to 
bear  in  mind  the  attendant  asthenic  state,  and  to  endeavour 
to  restore  the  general  health  to  the  highest  condition  possible. 
Appropriate  tonic  medicines  and  suitable  climatic  change,  with 
recourse  to  some  mineral  waters,  are  plainly  indicated. 

6.— Treatment  of  Special  Disorders  Dependent  on  the 
Gouty  Habit. 

It  is  essential  that  the  existence  of  a  gouty  dyscrasia  be  recog- 
nized in  any  case  where  it  exists,  and  to  determine  this  factor 
requires  skill  and  experience.  I  have  sufficiently  insisted  on  the 
importance  of  discovering  gouty  taint  in  cases  where  no  overt 
articular  attacks  have  occurred,  and  of  recognizing  goutiness  apart 
from  gout,  commonly  so  called ;  and  I  have  also  tried  to  indicate 
the  directions  wherein  such  knowledge  may  be  certainly  gained. 

As  may  readily  be  supposed,  many  diseases  occur  in  the  gouty 
which  are  quite  unconnected  with  their  special  habit  of  body,  and 
in  some  of  them  it  is  hardly  necessary  to  modify  the  treatment  in 
relation  to  that  habit.  A  gouty  tendency  tends  to  modify,  not 
seldom,  the  features  of  other  implanted  disorders,  and  often 
affords  grounds  both  for  prognosis  and  for  treatment. 


TREATMENT  OF  NERVOUS  SYMPTOMS.        379 

I  propose  to  discuss  methodically  the  treatment  of  special  gouty- 
disorders  according  to  the  several  systems  of  the  body.  It 
will  be  convenient,  however,  to  refer  to  some  gouty  ailments  apart 
from  a  strict  adherence  to  this  method.  Thus,  I  shall  treat  of 
asthma  under  the  head  of  the  respiratory  rather  than  that  of  the 
nervous  system,  and  of  angina  pectoris  as  a  cardio-vascular  rather 
than  a  neurotic  ailment. 

Nervous  System. — The  gouty  affections  of  the  nervous  system 
have  already  been  shown  to  be  numerous,  and  they  certainly  cover 
its  whole  area.  In  many  of  them,  an  attack  of  overt  gout  is  the 
natural  cure,  and,  not  seldom,  this  occurrence  is  the  first  feature 
which  discloses  the  true  nature  of  the  ailment  in  question.  This 
is  certainly  the  case  in  acute  mania,  melancholia,  and  hypochon- 
driasis. Attention  to  the  condition  of  the  functions  of  the  liver 
and  to  the  state  of  the  circulation  is  of  high  importance  in  deter- 
mining proper  treatment.  Where  the  cardio-vascular  system  is 
degenerate,  purgatives,  which  otherwise  are  of  value,  must  be 
cautiously  employed.  With  a  firm  pulse  and  a  hard  belly,  purga- 
tion is  very  advisable,  and  calomel  is  indicated. 

Alkaline  remedies,  such  as  sodium  phosphate  and  potass  salts, 
are  efficient,  also  ammonium  chloride  in  full  doses.  The  action 
of  the  skin  should  be  stimulated.  Butcher's  meat  is  to  be  given 
sparingly,  and  fish,  fats,  farinaceous  and  vegetable  food,  with  milk, 
are  advisable.  Exercise  in  the  open  air  is  necessary  as  soon  as 
practicable.  Any  articular  symptoms  call  for  ordinary  treatment 
by  colchicum  or  sodium  salicylate.  The  restraint  and  beneficial 
influences  of  a  well-ordered  maison  de  santi  are,  of  course,  neces- 
sary in  acute  mania  and  profound  melancholia.  Minor  degrees  of 
hypochondriasis  and  many  phases  of  psychopathy  may  be  best 
treated  at  home,  or  by  change  of  scene  amongst  suitable  surround- 
ings. Regular  gout  may  be  induced  to  alight  in  the  extremities 
in  some  of  these  cases  by  stimulating  pediluvia,  mercurial  purga- 
tives, or  by  a  full  dose  of  wine,  when  relief  will  come  to  many 
distempered  conditions  if  dependent  on  lurking  gout.  The  con- 
dition of  the  renal  functions  must  be  ascertained  in  any  case, 
especially  with  reference  to  the  employment  of  opium. 

Insomnia. — Where  this  is  dependent  on  any  obviously  direct 
gouty  condition,  appropriate  remedies  must  be  given  to  meet  it. 
The  diet  and  whole  regimen  require  revision,  special  attention 
being  paid  to  the  last  meal  taken.  Too  long  a  fast  before  retir- 
ing to  rest  is  harmful,  but  a  heavy  meal  is  best  avoided.  Beef- 
tea  or  any  animal  broth,  cocoa,  or  arrowroot  with  a  little  brandy, 


380   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

are  good  taken  an  hour  before  bedtime,  if  there  has  been  no  late 
dinner.  Sometimes,  a  little  fluid  extract  of  meat  taken  in  cold 
water  will  induce  sleep.  Hypnotics  constitute  the  last  resort, 
and  the  best  success  is  attained  without  them.  The  bromides  are 
the  least  harmful  of  such  agents,  but  should  be  given  early  in  the 
day  in  order  to  secure  their  soporific  effect  at  night.  Paraldehyde 
is  useful  where  the  heart  is  weak,  and  may  be  prescribed  in  doses 
of  thirty  or  fifty  minims. 

Where  there  are  acidity  and  gastro-duodenal  dyspepsia,  or  slow 
digestion — common  causes  of  insomnia  in  the  gouty — a  drachm 
of  compound  rhubarb  powder  in  peppermint  water  at  bedtime  is 
very  efficient.  Exercise  in  the  open  air,  driving  especially,  is  a 
powerful  aid  to  sleep,  and  bed  should  not  be  too  early  sought. 
A  dull  book  read  monotonously  by  some  one  is  often  effectual  in 
promoting  sleep.  Opiates  are  to  be  shunned,  and  I  am  confident 
in  affirming  that  they  can  safely  be  dispensed  with.  In  some 
cases  cannabis  indica  alone,  or  with  henbane  and  bromides,  is  very 
useful.  Chloral  hydrate  is  best  avoided,  if  possible.  Monobromated 
camphor  (gr.ii.— gr.  x.)  or  bromide  of  lithium  (gr.xv.— gr.xxx.)  may 
be  employed. 

In  winter,  if  the  feet  are  apt  to  be  cold,  a  hot  bottle  in  the  bed 
is  very  useful.  In  many  of  these  cases  the  patient's  statements 
as  to  his  rest  are  quite  untrustworthy,  and  more  sleep  is  obtained 
than  is  acknowledged.  In  severe  instances  of  insomnia  the  patient 
requires  assurance  and  encouragement  from  his  attendant,  and 
to  have  his  dread  of  dire  consequences  allayed. 

If  an  opium-habit  has  been  formed,  it  is  at  once  to  be  broken 
off,  and  every  care  taken  to  prevent  the  acquisition  of  the  drug. 
So  far  as  my  experience  guides  me,  no  risk,  but,  on  the  contrary, 
every  benefit  attends  this  line  of  practice. 

The  air  of  the  bedroom  should  be  fresh,  and  not  too  many 
articles  of  furniture  allowed  to  remain  in  it.  The  bed  should  be 
placed  in  the  centre  of  the  room,  not  facing  a  window. 

Attention  to  details  is  all  important  if  success  is  to  be  gained, 
and  such  minutige  are  as  much  a  part  of  clinical  medicine  as  the 
exhibition  of  any  drugs.      They  are  too  often  disregarded. 

Epilepsy. — Where  this  neurotic  tendency  prevails  in  the  gouty, 
there  is  evidence  sufficient  to  prove  that  it  can  be  powerfully 
modified  by  recasting  the  dietary.  Butcher's  meat  and  nitro- 
genous materials  are  to  be  withdrawn  as  far  as  possible,  and  fish, 
fatty,  vegetable,  and  farinaceous  food  must  replace  them.  Meat 
may  be  sparingly  taken  on  alternate  days,  or  even  less  often. 

In  some  cases  a  paroxysm  of  regular  gout  may  be  induced  with 


EPILEPSY.       HEADACHE.       HEMICRAN1A.  38 1 

much  benefit.  As  medicines,  the  bromides  are  of  as  much  value  as 
they  are  in  any  case  of  so-called  central,  or  idiopathic,  epilepsy,  but 
smaller  doses  will  be  found  effective  when  combined  with  alkalies, 
as  potass  salts  or  hypophosphite  of  sodium.  From  ten  to  twenty 
grains  of  potassium  bicarbonate  may  be  given,  with  as  much 
bromide  of  potassium  or  ammonium,  or  ten  grains  of  the  sodium 
hypophosphite.  Chalybeates  are  to  be  avoided.  The  action  of  the 
bowels  must  be  attended  to,  and  a  very  equable,  though  active, 
life  is  the  best  to  enjoin,  with  due  proportions  of  cerebral  and 
muscular  exercise. 

Occasional  mercurial  aperients,  at  intervals  of  three  weeks,  are 
likely  to  be  helpful  in  averting  attacks.  Duration  of  sleep  should 
not  exceed  seven  or  eight  hours,  and  none  should  be  permitted 
after  meals.  Venereal  excess  is  especially  harmful.  Stimulants 
must  be  taken  in  strict  moderation,  and  may  often  be  dispensed 
with.  Over-study  and  undue  excitement  are  to  be  avoided.  In 
such  cases  marriage  should  be  discountenanced,  or  at  any  rate 
postponed,  till  several  years  have  elapsed  without  any  epileptic 
manifestation. 

It  is  important  to  ascertain  the  presence  of  lead- impregnation 
in  cases  of  gout  with  epileptic  manifestations,  for  the  latter  may 
possibly  be  due  to  saturnine  influence  rather  than  to  gout,  or 
they  may  depend  upon  the  mixed  cachexia  induced  by  both 
taints. 

Headache. — Headache  of  gouty  origin  demands  treatment  for 
the  general  state  of  which  it  is  the  symptom.  Purgatives  con- 
taining mercury  are  commonly  useful,  and  alkalies  or  saline 
remedies.  Colchicum  is  found  to  be  of  value,  and  was  recom- 
mended by  Sir  Henry  Holland  for  this  purpose.1  Exercise  and 
aeration  are  always  indicated,  also  regular  exercise  in  respect 
of  brain-work  and  nervous  activity.  Periodical  purgatives  and 
suitable  diet  generally  avail,  and  chloride  of  ammonium  may  be 
taken  at  intervals. 

Hemierania. — Gouty  megrim  is  one  of  the  gravest  manifesta- 
tions of  imperfect  development  of  gout,  and  is  a  sore  vexation  to 
sufferers  by  reason  of  its  prostrating  and  incapacitating  character. 
The  treatment  relates  to  the  paroxysms,  and  to  the  intervals 
between  them.  The  attacks  may  begin  early  in  life,  but  happily 
tend  to  become  fewer  with  advancing  years,  and  they  may  pass 
away  altogether,  or  become  less  intolerable  after  the  fourth 
decade. 

Any  obvious  gouty  symptoms  must  be  treated  on  general  prin- 
1  Medical  Notes  and  Reflections,  p.  266. 


o 


82   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 


ciples.  The  conditions  leading  to  attacks  are  usually  recognized 
by  sufferers,  and  must  be  avoided  as  far  as  possible.  The  deter- 
mining causes  vary  infinitely  in  different  individuals. 

The  paroxysm  may  be  best  treated  by  rest  in  a  darkened 
room,  in  bed.  Hot  pediluvia  are  proper.  Cold  may  be  applied 
to  the  head  by  an  ice-bag  or  spirituous  lotion.  A  smart  purgative 
is  often  advisable,  and  may  be  given  in  the  form  of  a  few  grains 
of  calomel,  followed  up  by  compound  senna  mixture,  with  col- 
chicum.  If  the  stomach  is  irritable,  it  is  best  to  abstain  from  all 
food,  and  take  iced  soda-water  only.  Remarkably  good  effects 
follow  the  employment,  in  doses  of  ten  or  fifteen  grains,  of 
antipyrin,  repeated  in  two  hours'  time.  This  is  found  by  some 
sufferers  to  rob  the  disorder  of  its  terrors.  Bromide  of  caffeine  is 
sometimes  useful  in  doses  of  one  to  five  grains.  Tea  is  of  service 
in  some  cases,  and  so  is  a  short  period  of  sleep.  Undue  sleepiness 
sometimes  ushers  in  bad  attacks  on  the  morning  of  a  day  of 
suffering,  and  should  be  resisted.  I  have  known  a  short  journey 
into  the  country  abridge  an  attack,  and  have  also  found 
an  additional  quantity  of  wine  at  dinner  disperse  the  final 
twinges  of  agony.  The  more  important  part  of  treatment  consists 
in  care  after  the  attack,  with  a  view  to  avert  fresh  ones.  Regular 
hours,  equable  life,  freedom  from  worries,  abstention  from  evening 
entertainments,  especially  from  crowded  assemblies,  dinner-parties, 
hot  rooms,  and  mental  exhaustion,  should  be  enjoined.  Any 
undue  fatigue  is  bad.  Excessive  tobacco-smoking,  sight-seeing, 
visits  to  picture-galleries,  are  all  to  be  deprecated.  Over- 
taxed emotions  with  mental  anxiety,  or  tension,  often  induce  a 
paroxysm  within  a  few  hours'  time.  Periodical  purgatives  con- 
taining mercury  are  certainly  of  use,  and  a  course  of  arsenic 
is  one  of  the  most  potent  remedies  in  the  intervals  of  attacks. 
Alkalies  with  chloride  of  ammonium  are  indicated  in  many  cases. 
Change  of  air  and  all  means  which  raise  the  level  of  health  are 
favourable ;  and  all  the  powers  of  the  mind  and  body  should  be 
regularly  and  equally  exercised.  JVe  quid  nimis  is  the  motto  for 
any  sufferer  from  severe  migraine,  but  each  case  is  commonly 
idiosyncratic  in  respect  of  provocatives,  determinants,  and  thera- 
peutic agency. 

Gouty  Neuritis. — Gouty  neuritis  is  one  of  the  most  painful  and 
tedious  manifestations  of  irregular  gout.  It  is,  happily,  not  very 
common.  Ordinary  local  anodynes  seldom  avail  much  to  mitigate 
the  suffering.  So  much  so  is  this  the  case,  that  it  would  appear 
to  be  the  best  practice  to  begin  early  with  more  thorough  methods. 
I  think  most  highly  of  blistering  in  the  vicinity  of  an  inflamed 


NEURITIS.       NEURALGIA.  383 

nerve-trunk.  Strips  of  cantharidine  plaster  should  he  placed 
parallel  to  the  painful  tract,  and  the  resultant  blisters  kept  open 
by  Albespeyre's  paper  (No.  2)  for  some  weeks.  This  is  not  so 
severe  a  measure  as  it  would  appear,  and  is  more  rapidly 
efficient  than  most  other  means.  Mercurial  ointment  may  be 
applied  over  the  affected  nerve. 

If  these  plans  are  undesirable,  chloral  and  camphor,  or  menthol 
and  camphor,  one  of  the  former  to  two  or  three  of  the  latter,  may 
be  smeared  on  the  part.  Iodine  liniment  may  be  painted  in 
streaks  beside  the  nerve.  Cocaine  ointment  may  be  applied 
occasionally  as  an  anodyne.  Corrigan's  thermic  hammer  applied 
along  the  course  of  the  nerve  is  sometimes  efficacious. 

Internally,  quinine  with  iodide  of  potassium  is  indicated ;  full 
doses,  three  or  five  grains  of  the  former,  being  employed  twice 
or  thrice  a  day.  In  rebellious  cases,  arsenic  or  perchloride  of 
mercury  may  be  used.  I  do  not  recommend  resort  to  subcu- 
taneous use  of  morphia.  This  is  but  of  temporary  benefit,  and  is 
not  likely  to  prove  of  lasting  use  in  a  trouble  of  this  nature. 
With  the  best  treatment,  such  cases  are  not  likely  to  recover  in 
a  short  time,  and  with  ineffective  measures  the  painful  nerve  may 
continue  to  cause  torment  for  many  weeks  or  months.  Some 
relief  may  possibly  be  gained  from  time  to  time  by  the  action  of 
the  voltaic  electrical  current,  slowly  interrupted,  for  five  minutes 
at  each  operation ;  but  if  the  pain  is  aggravated  by  this  proceed- 
ing, it  must  not  be  repeated.  As  the  swelling  on  the  nerve-trunk 
subsides,  the  pain  gradually  passes  away,  but  dysassthesia  may 
remain  for  some  time  in  the  parts  supplied  by  the  affected  branch. 
Care  is  sometimes  needed  in  making  the  diagnosis  between  gouty 
and  peripheral  alcoholic  neuritis.  Alcohol  is  often  a  common 
factor  in  both  varieties  of  cases. 

Gouty  Neuralgia.  —  Neuralgia,  as  an  expression  of  the  gouty 
habit,  demands  treatment  directed  to  any  symptoms  of  that  habit 
which  may  be  present.  The  ordinary  causes  of  neuralgia  are 
to  be  sedulously  avoided,  exposure  to  cold  winds  and  damp  being 
particularly  provocative.  Any  dyspeptic  troubles,  and  constipation, 
are  best  treated  by  mercurial  aperients  and  alkalies.  Quinine 
with  alkalies  is  a  very  useful  combination,  and  chloride  of 
ammonium  is  valuable  in  full  doses.  Locally,  great  relief,  some- 
times immediate,  is  gained  by  the  voltaic  electrical  current,  the 
negative  pole  being  applied  to  the  nape  or  spine,  and  the  positive 
one  to  the  course  of  the  affected  nerve.  Only  feeble  currents  may 
be  used  for  any  cranial  nerve,  not  more  than  six  or  eight  cells  of 
a  Leclanche"  battery  being  employed. 


384   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

Menthol  and  camphor  paste  or  veratrina  ointment  may  be 
applied  locally.  In  severe  cases  morphine  may  be  required  hypo- 
dermically.  It  is  important  to  check  each  paroxysm  as  far  as 
possible,  and  not  to  permit  a  neuralgic  habit  to  supervene.  Some- 
times, a  full  dose  of  calomel  and  quinine  at  bedtime  proves  effectual 
to  cut  short  a  series  of  bad  attacks. 

The  neuralgia  following  herpes  zoster  after  middle  life  is  occa- 
sionally very  incoercible  in  the  gouty,  and  calls  for  anodynes  in 
addition  to  tonic  measures. 

Arsenic  is  of  great  value,  and  may  be  given  with  alkalies  for 
long  periods.  Change  of  climate  greatly  aids  other  methods  of 
treatment,  and  this  is  especially  observed  in  the  case  of  patients 
who  live  in  damp  and  low-lying  country-houses.  A  change  to 
the  drier  conditions  of  town-life  sometimes  proves  rapidly  bene- 
ficial. A  succession  of  flying  blisters  applied  near,  but  not  over, 
the  affected  nerve  affords  relief. 

Sciatica. — Sciatica,  or  hip-gout,  is  sometimes  due  to  gouty 
perineuritis  of  the  great  ischiatic  nerve.  In  other  cases  it  is  a 
true  neuralgia ;  while  again,  at  other  times  it  is  a  symptom  of 
arthritis  in  the  hip-joint.  The  latter  is  but  rarely  of  uratic 
variety,  and  most  frequently  due  to  chronic  rheumatic  arthritis. 
Corrigan's  thermic  hammer  and  successions  of  blisters  are  very 
useful  in  the  treatment  of  sciatica,  and  morphine  may  be  applied 
in  dressing  the  blistered  surfaces.  Hypodermic  injection  of 
morphine  is  also  useful  in  rebellious  cases.  Internally,  quinine 
and  purgatives  are  proper.  I  have  found  acupunctures  sometimes 
efficient. 

Daily  exercise  in  the  open  air  is  useful  for  post-herpetic  neu- 
ralgia, pursued  till  the  skin  becomes  moist.  Care  must  be  taken 
to  avoid  subsequent  chill.  All  sources  of  depression  and  ex- 
haustion must  be  shunned.  The  dietary  should  be  plain  but 
nutritious,  and  a  fair  proportion  of  fatty  food  is  proper  for  most 
cases.  Port  wine  may  be  taken  with  one  meal,  and,  in  most 
cases,  no  fear  need  be  entertained  of  inducing  gouty  symptoms 
by  this  means. 

The  patient,  and  not  the  disease,  is  to  be  treated.  In  every 
case,  the  urine  should  be  examined  for  glucose. 

In  summer,  a  high  inland  health-resort  should  be  sought,  Mal- 
vern, Ilkley,  or  Braemar  being  especially  suitable  localities,  and  a 
winter-season  may  be  advantageously  spent  out  of  England,  as, 
for  example,  at  Pau. 

Local  Gouty  Paralysis. — Local  paralyses  due  to  gouty  neuritis 
or  perineuritis  may  occasionally  be  met  with.      Facial  palsy  has 


CRAMPS.       VERTIGO.  385 

been  observed  in  this  connection,  as  in  a  case  mentioned  by  Garrod, 
where  the  symptoms  resolved  at  once  on  the  supervention  of  regu- 
lar gout.  The  musculo-spiral  nerve  may  be  thus  affected,  and 
of  this  form  of  paralysis  I  have  met  with  several  examples  in 
gouty  men,  all  of  whom  made  good  recovery  after  suitable  treat- 
ment. 

In  the  following  case  there  were  no  tender  points  detectible 
in  the  affected  arm,  but  the  ulnar  nerve  appeared  to  be  in- 
volved. 

W.  D.,  set.  forty-seven,  came  complaining  of  numbness  and  tingling,  with  marked 
weakness  in  the  left  hand.  He  was  a  window-cleaner.  He  had  had  several  attacks 
of  gout  in  the  feet.  He  drank  beer.  No  lead-impregnation.  The  fingers  were 
cramped,  and  he  could  not  close  his  hand.  He  had  not  slept  on  the  arm,  nor 
suffered  any  pressure  on  it.  Strict  diet  was  ordered,  and  bicarbonate  of  potassium 
with  colchicum.  The  hand  and  arm  were  bathed  with  hot  water,  and  cotton-wool 
was  applied  as  a  dressing.  In  four  days  there  was  improvement,  and  this  was  more 
marked  in  a  week.  The  muscles  of  the  affected  arm  reacted  normally  and  as  readily 
as  those  of  the  sound  limb.  Electro-sensibility  was  unimpaired.  The  ring  and 
little  fingers  remained  feeble,  with  kaksesthesia,  for  some  time.  No  swelling 
occurred  anywhere.     Perfect  recovery  followed. 

Cramp  in  Gout. — Cramp  of  the  sural  muscles  is  sometimes  a 
very  annoying  symptom  of  a  gouty  state  of  body.  It  may  pre- 
cede a  paroxysm  in  a  joint,  or  may  indicate  a  more  than  usually 
gouty  condition.  Antacids  are  of  use  in  removing  it.  A  very 
useful  prescription,  recommended  by  Dr.  Munk,  is  subjoined.1  A 
bandage  firmly  applied  from  the  dorsum  of  the  foot  to  the  knee 
is  sometimes  efficacious  in  preventing  recurrence  of  attacks. 

Gouty  Vertigo. — This  in  most  cases  is  a  result  of  gastric  disorder 
{vertigo  a  stomacho  Iceso),  but  may  be  purely  of  central  origin,  as 
an  expression  of  the  gouty  habit.  In  the  former  case,  treatment 
addressed  to  the  prevailing  form  of  dyspepsia  is  usually  successful, 
and  rapidly  so.  A  nightly  dose  of  compound  rhubarb  powder, 
and  an  alkaline  and  bitter  mixture  by  day  commonly  avail  to 
remove  the  symptom.  If  the  digestion  is  slow,  pepsine  with 
strychnine  and  mineral  acid,  taken  during  the  principal  meals,  is 
of  use.  In  the  case  of  "  central  "  vertigo,  an  attack  of  articular 
gout  sometimes  removes  the  symptoms.  Aperients  containing  mer- 
cury and  colchicum  are  then  fit  remedies.  To  prevent  discomfort 
from  attacks  of  giddiness  when  walking,  it  is  well  to  adopt  the 
simple  precaution  of  closing  one  eye.  The  eyes  should  be 
examined  in  each  case.      Sometimes,  a  degree  of  ophthalmoplegia 

1  R   Magnesii   Carbonatis,   Sulphuris  Prascipitati    Pulveris  Cubebas,  aa.  5i.     M. 
intime,  ut  fiat  Pulvis.     Sit  dosis  coch.  parvum  ex  lacte  hora  somni. 

2  B 


386      TREATMENT    OF    THE    SEVERAL   VARIETIES    OF    GOUT. 

externa  may  explain  the  vertigo,  demanding  fall  inquiry  into  the 
exact  nature  of  the  case. 

Hysteria. — Hysteria,  as  a  manifestation  of  inherited  gout,  can 
hardly  be  said  to  demand  any  special  medication  in  respect  of  its 
aetiology.  This  is  perhaps  true  for  most  examples,  but  there 
are  some  in  which  direct  anti-gouty  treatment  is  called  for. 

The  action  of  the  bowels  should  be  regulated,  and  the  circula- 
tion kept  as  active  as  possible.  The  dietary  should  be  as  nutri- 
tious as  can  be  taken.  These  patients  are  apt  to  be  very  poor 
eaters,  and  very  whimsical  in  their  appetites.  A  measured 
quantity  of  wine  with  at  least  one  meal  is  often  called  for. 
Exercise  is  imperative.  Great  care  is  necessary  in  repressing 
any  craving  for  stimulants  or  narcotics.  The  type  of  such  cases 
is  commonly  atonic,  and  no  lowering  measures  or  drugs  can  be 
borne.  Patience,  kindness,  and  firmness  are  necessary  both  on 
the  part  of  the  friends  and  the  attendant.  Every  encourage- 
ment to  effort  should  be  made,  and  all  morbid  introspection  and 
attention  directed  to  symptoms  should  be  as  far  as  possible 
dissipated.  Chalybeates  are  often  badly  borne,  in  which  case 
chloride  of  ammonium  with  nux  vomica,  and  cod  liver  oil  may 
be  usefully  employed.  Climatic  change  is  of  value,  especially  in 
winter  and  spring. 

Respiratory  System. 

Bronchitis. — A  tendency  to  bronchial  catarrh,  chronic  bron- 
chitis, and  emphysema  is  especially  noteworthy  in  gouty  subjects. 
The  gouty  element  in  any  such  case  should  be  duly  noted,  and 
treatment  modified  accordingly.  Alkalies  with  iodides  are  of 
especial  value,  combined  with  ammonium  salts.  Stimulating 
expectorants,  such  as  senega,  serpentary,  and  nux  vomica,  are 
useful,  and  where  there  is  bronchorrhoea,  terebine  in  five-minim 
doses  may  be  advantageously  employed.  Where  there  is  spasm, 
belladonna  or  stramonium  is  of  value,  together  with  iodide  of 
potassium.  Climatic  change  is  important  when  acute  symptoms 
have  passed  off,  and  certain  mineral  waters  may  also  be  taken  with 
benefit. 

Chronic  eczema  or  patches  of  psoriasis  may  alternate  in  activity 
with  gouty  bronchitis ;  and,  sometimes,  it  is  well  not  to  treat  the 
former  too  vigorously,  unless  they  prove  unduly  vexatious. 

Where  much  emphysema  exists,  there  is  especial  risk  of  pneu- 
monia in  those  of  gouty  habit,  and  it  is  apt  to  prove  fatal.  High 
arterial  pressure  may  be  met  with  in  some  cases. 


PNEUMONIA.       ASTHMA.  387 

Pneumonia. — Pneumonia  may  suddenly  supervene,  and  is,  some- 
times, plainly  a  form  of  visceral  gout.  It  demands  a  supporting 
line  of  treatment.  Quinine  with  alkalies,  or  iodide  of  potassium, 
and  alcohol,  according  to  the  state  of  pulse  and  degree  of  pyrexia, 
are  the  essential  remedies.  The  pulmonary  changes  may  rapidly 
alter.  The  condition  of  the  urine  should  be  examined.  Colchi- 
cum  may  prove  useful  in  conjunction  with  the  remedies  already 
mentioned.  Jacket-poultices  are  advisable,  as  in  ordinary  cases. 
Embolic  pneumonia  demands  special  attention  to  the  state  of  the 
circulatory  system,  and  calls  for  stimulants  and  supporting  treat- 
ment. These  cases  may  prove  tedious.  Severe  diarrhoea  may 
occur  in  connexion  with  gouty  pneumonia. 

Asthma. — This  is  most  often  associated  with  bronchitis,  but  may 
occur  in  pure  neurotic  forms,  or  as  a  phase  of  retrocedent  gout. 
In  the  latter  case,  it  is  proper  to  try  and  recall  the  gout  to  the 
part  vacated.  Indiscretions  in  diet  may  provoke  bronchial  spasm 
(peptic  asthma),  a,nd  the  special  peccant  article  comes,  in  time,  to 
be  discovered.  Various  inhalations  prove  of  value,  the  fumes  of 
a  powder  consisting  of  tobacco,  stramonium,  and  nitre  being  often 
helpful.1  Brown  paper  steeped  in  nitre  and  chlorate  of  potassium, 
dried,  and  impregnated  with  compound  tincture  of  benzoin,  is  use- 
ful to  burn,  and  the  fumes  should  be  inhaled  freely.  Two  grains 
of  caffeine  in  a  cup  of  coffee  will  give  relief  in  some  cases.  Bella- 
donna, stramonium,  and  alkalies  are  best  given  in  mixture,  or  a  pill 
containing  either  the  extract  of  belladonna  or  that  of  stramonium 
in  doses  of  a  fourth  or  third  of  a  grain  may  be  taken  once  or 
twice  a  day.  Iodide  of  potassium  and  belladonna  may  be  employed 
together,  or  with  small  doses  of  liquor  arsenicalis.  In  severe  and 
rebellious  cases  it  may  be  necessary  to  employ  morphine  by  the 
mouth  or  subcutaneously.  Chloral  hydrate  and  bromide  of  am- 
monium are  available,  and  a  few  whiffs  of  chloroform  or  gether  may 
be  inhaled,  at  the  hands  only  of  the  practitioner,  the  patient  being 
forbidden  to  dose  himself  in  this  fashion.  Nitrite  of  amyl,  or  iso- 
butyl,  capsules  may  be  thus  employed. 

For  the  neurosal  condition  attaching  to  the  arthritic  diathesis 
arsenic  is  of  supreme  value,  but  must  not  be  abused. 

Mercurial  aperients  with  colchicum  are  proper  at  intervals  in 
these  cases.  Lobelia  in  the  form  of  eetherial  tincture  is  some- 
times useful  in  doses  of  fifteen  or  twenty  minims  ;  and  so,  too,  are 
small  doses  of  ipecacuanha  wine  and  spirit  of  nitrous  eether. 

1  Ii.  Pulveris  Fol.  Stramonii  jfss.,  Pulveris  Anisi,  Potassii  Nitratis,  aa.  oij-,  Pulveris 
Tabaci  gr.v.  M.  intime  ut  fiat  Pulvis.  Sig.  A  teaspoonful  to  be  burnt  in  a  saucer, 
and  the  fumes  inhaled.     (Brompton  Hospital. ) 


388   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

Smoking  of  tobacco,  or  of  Joy's,  Grimault's,  and  datura  tatula 
cigarettes  may  be  employed  during  the  paroxysms. 

Attention  must  be  paid  to  the  condition  of  the  digestive  organs, 
and  a  dietary  suitable  for  the  gouty  must  be  enforced.  The  pre- 
sence of  any  textural  degenerations  and  the  degree  of  bronchial 
catarrh  must  be  noted  in  any  case. 

The  influence  of  climate  is  very  marked,  and  no  precise 
directions  can  be  given  without  regard  to  the  special  features 
of  the  case.  Moderately  high  and  dry  localities  are,  in  general, 
preferable  to  wooded  sites,  unless  in  the  region  of  pine  trees, 
which  flourish  best  on  sandy  and  dry  soils.  The  atmosphere 
of  towns,  being  dry  and  smoky,  suits  some  cases  best,  as  is  well 
known,  while  others  only  find  comfort  in  the  purest  air,  as  that 
of  the  sea.  Most  gouty  cases  do  well  at  Mont  Dore  or  Arcachon, 
at  Aix-les-Bains  and  Dax.  Subalpine  resorts  anywhere  on  the 
Continent,  or  the  climates  of  Bournemouth,  Bagshot,  Clifton,  Mal- 
vern, Ilkley,  or  Braemar  in  this  country,  are  available.  Inland 
or  mountain  influence  is  commonly  best  suited  to  all  arthritic 
cases,  and  in  Britain  it  is  difficult  to  get  away  from  all  marine 
impregnation.  The  variations  of  climate  anywhere  may  be  ex- 
treme within  very  circumscribed  limits,  since  much  depends 
on  soil,  drainage,  vegetation,  exposure,  and  shelter ;  and,  hence, 
important  differences  may  be  met  with  in  respect  of  a  few  feet  of 
altitude,  or  a  few  furlongs  of  distance. 

Circulatory  System. 

Disturbances  of  this  system,  due  to  gout,  are  revealed  by  such 
symptoms  as  inordinate  vascular  throbbings,  irregular  cardiac 
action,  varieties  of  cardiac  valvular  disease,  paroxysmal  cardiac 
neuroses,  and  the  disorders  due  to  faulty  nutrition  of  the  heart's 
walls  and  the  blood-vessels  generally. 

Inordinate  Arterial  Pulsations. — Inordinate  pulsations  of  the 
thoracic  and  abdominal  aorta  are  often  associated  with  phases  of 
gastric  disturbance.  They  come  and  go,  but  may  persist  for 
long  periods.  Remedies  and  dietary  suitable  for  any  prominent 
dyspeptic  symptoms  are  to  be  employed.  For  the  special 
symptom  of  rapid  and  violent  throbbing,  aconite  in  doses  of  three 
or  four  minims  of  the  tincture,  repeated  every  two  or  four  hours, 
is  useful.  This  drug  is  not  permissible,  however,  unless  the 
patient  is  generally  well-nourished  and  has  fair  digestive  capacity, 
and  it  must  be  given  only  under  supervision  of  the  attendant. 
In  other  cases,  bromides  of  potassium  or  sodium  are  often  valuable 


TACHYCARDIA.       IRREGULAR  ACTION  OF  THE  HEART.      389 

in  doses  of  ten  or  fifteen  grains  thrice  a  day.  Subsequently,  the 
mineral  acids  with  strychnia  are  available. 

Neurotic  Tachycardia. — For  pure  neurotic  tachycardia,  aconite, 
given  with  the  above  precautions,  may  be  prescribed.  Vascular 
throbbings  in  the  neck,  affecting  the  thyroideal  distribution,  may 
be  treated  with  ergot  or  with  digitalis,  and  these  drugs  may  also 
be  employed  in  other  forms  of  undue  pulsation.  Arsenic  is  useful 
in  long-continued  courses,  together  with  ordinary  measures  for 
promoting  nervous  tone  and  stability. 

Insomnia. — Insomnia  is  sometimes  a  result  of  these  conditions, 
and  may  be  relieved  by  bromides,  moderate  alcoholic  stimulation, 
especially  in  the  elderly  and  cachectic,  and  by  half-drachm  doses 
of  paraldehyde  at  bedtime.  Monobromated  camphor  in  doses  of 
three  or  five  grains,  musk  in  two  to  five  grain  doses  in  pill,  or 
tincture  of  sumbul  in  half-drachm  doses,  are  all  available,  and 
may  be  had  recourse  to  in  turn.  Climatic  change,  if  suitably 
secured,  is  often  of  value  in  re-establishing  the  condition  of 
neurasthenia,  on  which  many  of  these  untoward  symptoms 
depend. 

Irregular  Cardiac  Action. — Irregular  cardiac  action  may,  or  may 
not,  be  a  symptom  indicating  gravity.  It  sometimes  persists 
through  a  long  gouty  life  without  serious  significance,  or  it  may 
occur  occasionally,  as  a  phase  of  visceral  gout,  in  which  case 
treatment  for  that  state  is  demanded.  If  it  be  a  retrocedent  mani- 
festation, endeavours  must  be  made  to  restore  gouty  action  in  the 
part  lately  affected.  The  condition  of  textural  nutrition,  and  that 
of  the  valves  of  the  heart,  is  to  be  determined  in  any  such  case. 
Stimulation  is  usually  necessary  where  failure  exists,  whether  due 
to  defective  nerve-power  or  to  parietal  weakness.  Defective  com- 
pensation in  the  walls,  with  dilatation  of  cavities,  calls  for  digitalis 
and  strychnia,  alone,  or  together,  with  eether,  and  a  subsequent 
dosage  with  arsenic  and  strychnia,  with  or  without  some  chaly- 
beate, according  to  circumstances.  Digitalis  is  to  be  avoided  in 
cases  of  aortic  valvular  disease  involving  reflux,  and  replaced  by 
belladonna ;  and  the  ordinary  rules  must  guide  the  treatment  of 
mitral  reflux.  In  mitral  constriction  digitalis  is  often  useful  for 
a  time,  but  the  patient  must  be  carefully  watched  while  taking 
it.  Tincture  of  strophanthus  is  of  value  in  any  case  of  cardiac 
parietal  debility,  and  in  doses  of  four  or  six  minims  has  no  ten- 
dency, so  far  as  I  know,  to  induce  unwelcome  symptoms.  Conse- 
cutive changes  on  the  right  side  of  the  heart,  such  as  dilatation 
with  tricuspid  reflux,  may  be  treated  in  the  gouty,  as  in  any  other 
patient,  on  general  principles,  not  omitting  venisection,  if  need  be. 


390   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

The  prognosis  is  especially  unfavourable  in  cases  with  progres- 
sive vascular  degeneration  and  interstitial  nephritis.  Iodides  in 
small  doses  with  nux  vomica  are  amongst  the  best  general  reme- 
dies for  this  state,  and  paraldehyde  and  cannabis  indica  are  the 
safest  hypnotics  when  such  are  required. 

Pseudo  -  Angina  Pectoris. — Pseudo- angina  pectoris  is  usually 
associated  with  gastric  disturbance  and  extreme  flatulency.  The 
symptoms  may  thus  simulate  gout  of  the  stomach.  They  occur 
in  persons  younger  than  the  subjects  of  true  angina.  The  heart  is 
found  to  be  free  from  signs  of  organic  disease,  and  there  may  be 
no  signs  of  vascular  degeneration.  For  immediate  relief,  stimu- 
lants are  necessary.  Brandy,  sal  volatile,  or  aether  may  be  given, 
or  a  carminative  draught  containing  bicarbonate  of  sodium,  spirit 
of  cajuput,  compound  tincture  of  lavender  and  peppermint  water. 
A  large  linseed  and  mustard  poultice  should  be  applied  to  the 
epigastrium.  A  dose  of  compound  senna  mixture,  with  half  a 
drachm  of  wine  of  colchicum,  may  be  given  on  the  subsidence 
of  the  urgent  symptoms,  and  a  mercurial  purge  may  sometimes 
precede  this.      A  hot  pediluvium  will  afford  relief. 

True  Angina  Pectoris. — True  angina  pectoris  with  associated 
organic  cardio-vascular  changes  demands  different  management. 
Capsules  of  amyl  nitrite,  or  iso-butyl  nitrite,  should  always  be  at 
hand  for  inhalation,  and  carried  by  day  in  the  pocket  of  the  suf- 
ferer. A  tablet  of  nitro-glycerine  ( I .  I  oo  gr.)  taken  twice  or  thrice 
in  the  course  of  the  day  is  often  effectual  in  warding  off  paroxysms. 
Stimulants  are  necessary,  and  in  protracted  pangs,  morphine  used 
hypodermically  must  be  used,  but  only  by  the  medical  attendant.1 
Veratrina  ointment,  or  belladonna  and  chloroform  liniment  in 
equal  proportions,  may  be  applied  to  the  praecordia.  Compound 
spirit  of  aether  in  a  dose  of  twenty  minims  may  be  given  with  as 
much  of  the  liquor  morphinee  acetatis  in  camphor  water,  regard 
being  had  to  the  state  of  the  kidneys.  The  special  cardiac  and 
neurosal  condition  demands  treatment — arsenic,  strychnia,  bella- 
donna, and  iron  being  of  use  for  cases  where  parietal  softening  is 
surmised  to  exist.  Inasmuch  as  paroxysms  are  apt  to  occur  on 
the  supervention  of  sleep,  amyl  nitrite  capsules  and  an  anodyne 
draught  should  be  in  readiness  at  the  bedside.  The  patient 
should  be  kept  quiet,  and  free  from  all  forms  of  emotional  dis- 
turbance. 

Haemorrhages Haemorrhages  occurring  in  the  gouty  demand 

little  or  no  special  treatment.     They  check  themselves,  and  work, 

1  No  nurse,  or  even  "  trained  "  nurse,  should  ever  be  permitted  to  practise  any 
hypodermic  form  of  treatment. 


HEMORRHAGES.       PHLEBITIS.  39 1 

possibly,  some  good  in  many  cases,  certainly  little,  if  any,  mischief. 
Management,  not  treatment,  is  called  for. 

Phlebitis. — Phlebitis,  as  a  gouty  manifestation,  requires  careful 
treatment.  The  gouty  nature  of  the  ailment  must  be  clearly 
recognized,  as  also  the  full  gravity  of  the  case.  It  may  be  very 
unimportant  in  many  instances  in  the  long-run,  but  may  never 
be  made  light  of  while  present.  In  any  case,  the  patient  should 
be  kept  on  suitable  regimen,  and  treated  for  at  least  two  months 
till  all  signs  of  the  disorder  have  subsided,  and  the  clot  is  disposed 
of  or  rendered  harmless. 

The  calf  of  the  leg  is  the  commonest  site,  but  the  upper 
extremities  may  be  implicated  ;  and  the  most  serious  examples 
are  those  involving  the  axillary  vein,  or  some  vein  at  the  root  of 
the  neck  Eecumbency  is  essential,  and  due  warning  must  be 
given  of  the  danger  of  sudden  movements  or  flexion  of  the  limbs. 
Erect  posture,  if  assumed,  must  be  arrived  at  with  care,  and  if  a 
lower  limb  is  involved,  it  should  be  spared  in  such  actions  as 
getting  into  bed  or  dressing.  The  dangers  are  of  embolism  of  the 
pulmonary  artery,  and  syncope  with  apnoea,  and  they  are  apt  to 
occur  both  early  and  late  in  the  course  of  the  disorder.  There 
may  be,  in  some  of  these  cases,  latent  chronic  nephritis,  and  a 
feeble  condition  of  the  heart. 

The  condition  of  the  blood  is  that  of  hyperinosis,  with  dimin- 
ished alkalinity.  This  is  to  be  met  by  a  diet  sparing  in  nitro- 
genous elements,  and  by  a  free  use  of  vegetable  food  and  of  diluents. 
Fish  and  farinaceous  food  may  be  given ;  and  alcohol,  best  in  the 
form  of  whisky  or  brandy,  is  generally  of  value  to  maintain  a 
vigorous  circulation  and  check  the  tendency  to  blood-stasis. 

Vegetable  food  is  preventive  of  hyperinosis.  Some  mineral 
water,  as  that  of  Vichy  or  Selters,  is  useful  to  the  extent  of  a  pint 
in  the  day. 

If,  as  sometimes  happens,  there  is  much  pain  in  the  track 
of  the  inflamed  vein,  warm  fomentations  with  belladonna  or 
laudanum,  or  both,  are  desirable.  No  leeching,  and  no  frictions, 
are  to  be  practised.  The  limb  should  be  placed  at  rest,  slightly 
raised,  and  a  cradle  placed  over  it.  Belladonna  ointment  may  be 
spread  thickly  on  lint  and  applied,  or  oleate  of  morphina  smeared 
over  the  part,  a  tailed  domet  bandage  covering  all. 

Internally,  saline  aperients  are  proper,  as  sulphate  and  car- 
bonate of  magnesium,  with  senna  and  colchicum,  which  may  be 
given  as  an  occasional  morning  dose  ;  or  four  ounces  of  any  bitter 
water,  as  Hunyadi  Janos,  Rubinat,  or  Piillna,  may  replace  this  at 
intervals.      Quinine  with  potassium  bicarbonate  and  ammonium 


392   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

carbonate  is  serviceable  at  first,  and  quinine,  mineral  acids,  and 
strychnia  are  to  be  employed  later. 

Some  degree  of  oedema  of  the  affected  limb  may  remain,  with 
enlargement  and  unnatural  sensations,  for  varying  periods  after 
an  attack ;  and  if  a  considerable  vein  has  been  sealed,  these  may 
be  abiding  conditions,  requiring  an  elastic  stocking  to  be  worn. 
Gentle  friction  and  warm  douchings  may  do  much  in  due  time 
to  overcome  these,  but  are  not  to  be  thought  of  till  all  signs  of 
activity  in  the  ailment  have  long  passed  away. 

Recurrence  is  very  apt  to  happen  if  a  thorough  recovery  is  not 
secured,  and,  hence,  much  disappointment  may  come  from  unheeded 
advice,  or  too  pliable  counsels  on  the  part  of  the  attendant.  On 
trivial  provocation,  attacks  of  phlebitis  are  also  prone  to  occur  in 
those  predisposed  to  this  form  of  gouty  trouble,  and,  hence,  such 
pursuits  and  exercises  as  tend  to  determine  them  must  be  forsworn 
for  the  future.  With  lessened  tendency  to  gout  comes  also  lessened 
tendency  to  this  variety  of  it. 

In  cases  of  embolism,  if  the  clot  be  large,  a  fatal  result 
within  a  few  moments  is  almost  certain.  Smaller  portions  of  a 
friable  clot  may  reach  the  lungs  and  induce  sudden  symptoms, 
sometimes  alarming  enough,  but  commonly  eventuating  in  pneu- 
monia with  bloody  sputa,  pyrexia,  and,  sometimes,  septical  symp- 
toms, demanding  quinine,  ammonia,  and  stimulants. 

Gouty  Affections  of  the  Tongue  and  Fauces. 

Lingual  Neuralgia. — Neuralgic  pains  in  the  tongue  commonly 
pass  off  without  treatment.  Sore  tongues,  with  psoriasis  and 
thickening,  are  relieved  by  taking  food  not  too  hot,  and  by  avoid- 
ing salt  and  tobacco-smoking.  A  saturated  solution  of  chromic 
acid  may  be  painted,  at  intervals  of  a  week,  over  white  patches  oc- 
curring on  the  tongue.  Balsam  of  Peru  may  be  thus  used  more 
frequently.  Boracic  lotions  are  soothing,  with  or  without  chlorate 
of  potassium.  Regulated  dietary,  with  (if  any)  a  moderate  allow- 
ance of  stimulants,  is  to  be  prescribed. 

Tonsillitis. — Tonsillitis  is  best  treated  at  first  by  sucking  ice, 
and  a  dose  or  two  of  two  ounces  of  the  mistura  guaiaci.  After 
twenty-four  hours  guaiacum  is  of  no  avail.  Salicylate  of  sodium 
is  often  efficacious,  and  is  to  be  given  in  doses  of  from  fifteen  to 
twenty  grains  every  two  hours  at  first,  subsequently  every  four 
or  six  hours.  Warm  gargles  of  borax  and  camphor  water  are 
soothing,  or  solution  of  cocaine,  ten  to  twenty  per  cent.,  may  be 
painted  over  the  fauces.      A  mercurial  or  saline  aperient  is  neces- 


TONSILLITIS.       DISORDERS    OF    THE    LIVER.  2>93 

sary,  and  quinine  with  tincture  of  cinchona  may  be  given  for 
some  days  as  the  trouble  subsides.  The  throat  may  be  rubbed 
with  compound  camphor  liniment,  and  cotton-wool  applied  for 
some  days.  It  may  be  necessary  in  some  cases  to  give  three  or 
four  ounces  of  port  wine  daily  with  meals.  One  tonsil  is  com- 
monly more  involved  than  the  other.  Suppuration  is  the  excep- 
tion in  these  cases,  and  ulcerative  or  herpetic  forms  are  less 
frequent  than  in  other  varieties  of  tonsillar  angina.  The  trouble 
may  rapidty  subside  on  the  occurrence  of  gouty  arthritis.  After 
middle  life,  gouty  angina  faucium  is  less  frequently  met  with. 

Parotitis. — Gouty  inflammation  of  the  parotid  gland  may  occur 
spontaneously,  or  by  metastasis.  It  has  not  been  known  to 
precede  orchitis,  or  to  be  in  any  relation  to  it.  Treatment  must 
be  conducted  on  general  principles,  colchicum  proving  promptly 
useful.  Belladonna  liniment  should  be  applied,  cotton-wool  laid 
over  the  part,  and  gout  be  recalled  to  any  previously  involved 
joint.  Sometimes,  no  treatment  is  of  avail,  relief  only  coming  with 
the  supervention  of  arthritis.  One  gland  may  be  attacked,  then  a 
joint,  and  after  an  interval  the  other  gland  may  become  inflamed. 

Digestive  System. 

I  have  already  discussed  the  treatment  of  the  varieties  of 
dyspepsia  met  with  in  the  gouty,  and,  in  particular,  the  special 
forms  of  visceral  gout  which  affect  the  alimentary  canal.  It 
remains  to  be  stated  that  many  of  the  disorders  of  this  system, 
including  hepatic  derangements,  are  most  efficiently  treated  by 
hydro-therapeutic  measures  conducted  on  principles  derived  from 
experience  at  the  various  Spas  and  health-resorts.  I  shall  refer 
to  these  more  at  length  in  the  chapter  on  balneology  and  hydro- 
therapeutics.  A  course  of  hot-water:drinking  may  often  be 
taken  with  advantage  at  home.1 

Gouty  Affections  of  the  Liver. — In  most  gouty  cases  the  dis- 
orders of  the  liver,  with  the  exception  of  formation  of  biliary 
calculi,  belong  to  the  so-called  functional  class,  and  have  as  yet 
no  definitely  recognized  morbid  anatomy,  because  they  are  for  the 
most  part  fleeting,  and  do  not  entail  structural  changes.  In  a 
minority  of  cases,  where  alcoholism  has  prevailed,  ordinary  cirrhotic 

1  Dr.  Haig  believes  that  dyspepsia  may  result  from  hepatic  congestion  due  to 
retention  of  uric  acid  in  the  liver.  There  thus  results  a  general  diminution  of  ab- 
sorption and  of  nutritive  changes,  with  lessened  formation  of  urea  and  uric  acid,  and 
a  fall  in  acidity  of  the  blood.  As  a  result  of  the  latter  comes  a  rush  of  uric  acid  into 
the  blood,  with  the  supervention  of  headache  or  a  gouty  attack.  When  any  drug  dis- 
turbs digestion,  there  is  always  a  fall  in  acidity,  and  a  rise  in  excretion  of  uric  acid. 


394   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

changes  may  pix>ve  complications,  demanding  treatment  on  general 
principles.  Most  often,  we  have  to  deal  with  some  degree  of 
tumidity,  and  more  or  less  hepatalgia.  The  portal  venous  system 
may  be  engorged,  and  piles  may  result.  Gastric  catarrh  is  a 
necessary  concomitant.  Constipation  may  result,  and  the  stools 
be  paler  than  natural,  and  knotty  in  character. 

Attacks  of  this  nature  constitute  a  variety  of  visceral  gout. 
The  tendency  for  uric  acid  to  be  retained  in  the  liver  in  persons 
of  gouty  habit  must  be  borne  in  mind,  and  such  retention  cannot 
fail  to  be  noxious  in  various  ways.  Headache,  mental  depression, 
irritability  of  temper,  and  lassitude,  with  loaded  uratic  urine,  are 
but  some  of  the  symptomatic  indications.  Mercurial  purgation 
and  sodium  salts,  with  colchicum,  prove  effectual  in  relieving  these 
troubles,  and  alkalies  with  chloride  of  ammonium  are  also  of  value. 

Biliary  Calculi. — The  same  line  of  treatment  is  proper  when 
biliary  calculi  form,  and  threaten  to  pass.  Restricted  diet  is  of 
great  importance,  and  farinaceous  food  is  sometimes  to  be  spar- 
ingly used  in  these  cases.  Fish,  thin  broths,  and  green  vegetables 
are  rather  indicated  than  more  concentrated  liquid  nourish- 
ment. Many  mineral  waters  are  of  great  value.  Exercise  is 
imperatively  necessary,  and  brisk  walking  or  riding  are  the  best 
forms  of  it. 

Glycosuria  and  Gouty  Diabetes. — Glycosuria  is  one  of  the  most 
marked  symptoms  of  hepatic  gout.  I  have  already  discussed  the 
causation  and  symptoms  of  this  disorder  at  length. 

It  is  before  all  things  important  to  recognize  the  arthritic 
element  in  these  cases.  The  treatment  is  in  the  first  instance 
regulated  by  such  recognition.  As  in  other  forms  of  the  malady, 
it  is  fortunate  if  the  glycosuria  be  early  detected.  The  amount 
of  urine  daily  passed,  and  the  degree  of  saccharine  impregnation 
should  be  ascertained,  as  also  the  influence  of  digestion  on  the 
amount  of  sugar.  The  patient's  weight  should  be  taken  weekly 
or  monthly.  At  first,  it  will  certainly  be  proper  to  employ  re- 
stricted diet,  and  to  watch  its  effects  carefully.  The  glycosuria 
may,  or  may  not,  pass  off  completely,  and  if  it  disappear,  the  diet 
may  be  made  more  natural  by  degrees.  Digestion  must  be  kept  at 
the  highest  standard.  It  will  generally  be  found  that  the  patient 
is  conscious  of  better  digestion  when  the  special  diet  is  not  too 
strict,  or  too  long  persisted  in.  If  there  is  a  strong  gouty  tendency, 
fish  and  fowl,  and  avoidance  of  red  meats  may  be  beneficial ;  and 
whatever  is  bad  for  gout  will  in  any  case  be  bad  for  the  glycos- 
uria. It  is  usually  found  in  the  earlier  stages  that  the  sugar 
is  easily  removed  by  dietetic  measures  alone. 


GLYCOSURIA  AND    GOUTY    DIABETES.  395 

The  medicinal  treatment  necessarily  varies  with  each  individual. 
Alkalies  occupy  the  first  place,  both  for  regulating  the  digestion  and 
dispersing  the  glucose  in  the  blood.  Effervescing  citrate  of  sodium, 
citrates  of  ammonium  and  potassium  may  be  used,  and  cinchona 
and  nux  vomica  may  be  given  with  them.  It  is  a  good  plan  to 
give  such  a  course  for  a  week  or  ten  days  in  each  month,  as  was 
advised  by  Trousseau.  Arseuic  is  another  drug  of  decided  value 
as  a  nutrient  and  nervine  tonic,  and  is  best  given  in  from  five 
to  ten  minim  doses  of  Fowler's  solution  twice  daily  after  food. 

All  possible  aid  must  be  secured  from  the  best  hygienic 
measures.  The  action  of  the  muscles  must  be  enforced  by  regular 
open-air  exercise,  and  that  of  the  skin  be  well-promoted.  An 
open-air  life  is  of  the  highest  importance.  Physical  exertion 
appears  to  diminish  glycosuria.  In  summer,  recourse  should  be 
had  to  some  high  inland  health  resort  or  Spa,  and  amongst  these 
Carlsbad,  Kissiugen,  Vichy,  Oontrexeville,  Plombieres,  and 
Neuenahr  are  in  repute.  Cases  of  "  diabetes "  are  annually 
reported  to  be  "  cured  "  at  each  of  these,  and  at  other  watering- 
places.  M.  Debout  d'Estrees  has  observed  at  Oontrexeville  that 
the  elimination  of  uric  acid  is  simultaneous  with  the  disappear- 
ance of  glucose  during  treatment  there.1 

Without  doubt,  these  cures  sometimes  occur,  and  it  is  in  cases 
of  this  class,  and  in  other  mild  forms  of  the  disorder,  that  they 
are  wrought.  The  out-door  life  and  the  regular  habits,  with 
freedom  from  cares  and  vexations,  do  much  to  aid  the  hydro- 
therapy. The  only  stimulants  permissible  are  good  Bordeaux 
wine,  taken  with  water,  or  old  whisky  well-diluted. 

In  the  chronic  form,  the  diet  must  be  relaxed  in  respect  of 
amylaceous  matters,  lest  the  patient  waste,  grow  dyspeptic,  dis- 
contented, and  become  cachectic.  Well-toasted  white  bread, 
"  pulled  "  bread,  brown  bread,  rice,  macaroni,  onions,  and  beans 
may  be  allowed  in  moderate  quantity,  and,  at  intervals,  half  a 
potato.  Cream  and  fatty  food  are  of  much  value,  and  milk  need 
not  be  stinted.  Asparagus  should  be  avoided.  Mischief  due  to 
errors  of  diet  will  soon  betray  itself  in  wasting,  diuresis,  languor, 
thirst,  and  by  examination  of  the  urine,  and  such  symptoms  call 
for  stricter  diet,  at  all  events  for  a  time. 

All  sources  of  irritation  to  the  liver  are  to  be  carefully  guarded 
against.  If  purgation  is  called  for,  Homburg  salts,  castor  oil,  or 
blue  pill  and  colocynth  mass,  are  amongst  the  best  agents. 

Dr.  Schmitz  of  Neuenahr  remarks,  that  "  it  is  exactly  in  this 
form  of  diabetes  that  alkaline  waters  and  salicylate  of  sodium  are 

1  Brit.  Med.  Jour.,  February  23,  1884,  p.  587. 


396      TREATMENT    OF   THE    SEVERAL   VARIETIES    OF    GOUT. 

found  to  be  so  beneficial,  because  both,  are  known  to  be  efficient 
remedies  against  the  root  of  evil,  viz.,  the  gout."  He  has  often 
observed  an  immediate  and  material  improvement,  and  frequently 
a  complete  disappearance  of  diabetes  after  an  acute  attack  of 
gout ;  also,  that  diabetes  reappeared  whenever  usually  recurring 
attacks  of  gout  failed  to  come  out. 

He  emphatically  condemns  strictly  anti-diabetic  diet  in  these 
cases,  inasmuch  as  it  is  too  nitrogenous,  and  tends  to  maintain 
the  gouty  state  ;  and  he  urges  that  the  measure  of  assimilative 
capacity  for  farinaceous  food  should  be  ascertained  carefully  in 
each  case,  white  and  brown  bread  being  allowed,  as  also  rice, 
macaroni,  dried  peas,  lentils,  and  beans,  and  a  fair  quantity  of 
milk  ;  cane-sugar  and  dextrine  being  rigidly  excluded  in  all  cases. 
Saccharin  may  be  employed  as  a  sweetening  agent,  if  desired. 

My  own  experience  is  fully  in  accordance  with  that  of  Dr. 
Schmitz. 

As  a  rule,  cases  of  this  class  respond  very  promptly  to  re- 
stricted diet,  and  in  a  few  days  all  traces  of  glucose  may  dis- 
appear from  the  urine.  A  corresponding  improvement  takes 
place  in  the  general  health  and  comfort  of  the  patient.  Weight  is 
regained,  and  the  sense  of  malaise  passes  off.  Ordinary  diet  may 
then  be  gradually  resumed.  No  hard  and  fast  line  can  be  laid 
down  as  to  restricted  diet  for  these  cases  as  a  class.  Each  one 
must  be  separately  studied. 

In  all  cases  it  is  well  to  regard  the  patient  as  an  invalid,  and, 
without  causing  undue  anxiety,  it  is  important  to  let  him  regard 
himself  as  a  valetudinarian.  There  will  thus  be  a  better  chance 
for  implicit  obedience  as  to  diet  and  regimen,  and  less  chance  of 
exposure  to  overwork,  worry,  or  bad  weather.  It  is  necessary  to 
lay  stress  upon  this  point,  because  many  of  these  patients  feel,  at 
times,  in  excellent  health,  and  look  remarkably  robust.  They  thus 
deceive  themselves  and  their  friends.  No  case  may  be  lightly 
regarded.  The  chances  of  textural  damage  to  the  kidneys  and 
cardio-vascular  system  must  not  be  lost  sight  of  in  any  chronic 
case.  The  glycosuria  becomes  of  less  importance  as  such  graver 
indications  supervene. 

In  cases  where  there  are  plainly-marked  arthritic  concomitants, 
it  has  long  been  observed  as  a  good  sign  that  uratic  deposits 
occur.  Elliotson  mentioned  this,  also  Prout.  More  recently, 
Bence  Jones,  Garrod,  Pavy,  and  Beale  have  affirmed  the  same. 
Another  promising  indication  is  a  moderate  amount  of  urine,  the 
specific  gravity  of  which  does  not  exceed  1.035-  Very  much 
depends  upon  early  recognition  of  the  glycosuria.      Many  cases 


GLYCOSURIA    AND    GOUTY    DIABETES.  397 

Lave  unfortunately  made  much  progress  before  sugar  is  detected, 
its  presence  not  being  suspected,  because  so  many  of  the  common 
symptoms  of  ordinary  diabetes  are  absent.  Sir  William  Roberts 
is  inclined,  from  his  experience,  to  give  a  rather  gloomy  prognosis, 
regarding  the  health  as  broken,  as  he  found  death  occur  in 
from  two  to  four  years  from  cerebral  disease  or  pulmonary  com- 
plications. 

On  the  other  hand,  cases  have  been  known  to  go  on  for  ten, 
twelve,  and  even  twenty-three  years.  With  such  a  disparity 
before  us,  it  is  plain  that  no  definite  opinion  can  be  given  in  a 
general  way.  Each  case  must  be  regarded  by  itself,  and  the 
effects  of  the  disorder  be  studied  upon  the  individual.  The  sig- 
nificance of  the  glycosuria  thus  varies  infinitely  in  different  cases. 
So  much  so  is  this  the  case,  that,  as  M.  Lasegue  declares,  one 
must  study  diabetes  indefatigably  for  fifteen  or  twenty  years  before 
one  can  know  much  about  it :  "  C'est  une  maladie  a  l'usagfe  ex- 
clusif  des  vieux  praticiens." 

Many  of  the  subjects  of  this  variety  of  diabetes  are  robust  and 
of  good  constitution,  and  the  disorder  must  cease  to  exist  in 
a  latent,  intermittent,  or  mild  form  before  any  marked  derange- 
ment of  general  health  is  declared.  Even  then,  much  may  be 
done  to  restore  the  wasted  textures  and  the  accompanying  loss  of 
energy,  and  happily,  in  many  instances,  with  advancing  years  the 
glycosuria  loses  its  importance  as  a  symptom. 

Schmitz  observes  that  gouty  diabetes  has  the  best  prognosis  of 
all  the  forms  of  the  disorder. 

It  is  well  if  restricted  diet  speedily  removes  the  glycosuria, 
and  long  intervals  are  passed  without  a  return  of  it. 

From  time  to  time  sugar  appears  in  the  urine,  and  a  recru- 
descence takes  place,  and  this  occurrence  would  seem,  sometimes, 
to  indicate  that  attacks  of  glycosuria  replace  those  of  more 
obvious  gout,  to  which  the  patients  may  have  previously  been 
subject.  The  same  causes  which  are  effective  to  bring  out 
gout  will  here  elicit  glycosuria  in  its  stead. 

In  some  of  these  cases  urine  becomes  of  low  specific  gravity, 
and  albumen  appears,  the  quantity  of  urine  continuing  large,  not, 
as  Sir  William  Gull  points  out,1  because  there  is  much  sugar  to 
be  discharged,  but  as  a  result  of  damage  to  the  kidneys,  which, 
together  with  the  blood-vessels,  become  fibrotic,  as  part  of  the 
general  gouty  cachexia.  Hence,  glucose  may  be  found  in  these 
cases  in  urine  of  as  low  specific  gravity  as  1.006,  but  the  patient's 
condition  is  to  be  estimated  in  this  stage  rather  by  the  renal  and 
1  Private  communication. 


39§   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

vascular  changes  than  by  the  degree  of  glycosuria,  which  may 
be  unimportant. 

Intelligent  patients,  on  learning  that  they  present  symptoms 
of  diabetes,  are  naturally  apt  to  be  greatly  perturbed  and  de- 
pressed. This  mental  condition  is  a  most  disastrous  one.  It  is 
of  especial  importance  to  hold  out  as  encouraging  a  prognosis  as 
possible,  while  the  necessary  dietetic  directions  are  vigorously 
enforced,  and  every  effort  is  made  to  improve  the  general  health. 


Cases. 

I  shall  not  do  more  than  record  the  leading  features  of  some 
cases  which  have  come  within  my  own  observation,  and  which 
sufficiently  illustrate  the  character  of  this  variety  of  diabetes. 

Case  i. — A  robust  and  rather  corpulent  man  was  found  to  have  glycosuria 
when  about  forty  years  of  age.  He  came  of  distinctly  gouty  family.  Had  suf- 
fered from  gout  for  some  years  at  intervals,  and  had  been  actively  treated  for  it. 
Restricted  diet  did  not  avail  to  remove  sugar  entirely  from  the  urine.  No  loss  of 
flesh,  but  sense  of  muscular  weakness,  and  fatigue  easily  induced.  Attacks  of 
gout  continued,  and  seemed  to  be  kept  in  check  by  several  Turkish  baths  taken 
in  each  month.  Subsequently  the  sugar  disappeared  from  the  urine,  and  was  at 
one  time  apparently  replaced  by  free  uric  acid.  This  patient  has  remained  for 
about  seventeen  years  in  good  health,  and  leads  an  active  life.  A  brother  suffers 
from  diabetes  in  a  severe  form,  and  for  years  has  passed  urine  of  specific  gravity 
varying  from  1.060  and  upwards  ;  he  takes  an  ordinary  mixed  diet. 

CASE  2. — A  lady,  aged  about  forty-four  years,  inheriting  gout  from  one  and 
perhaps  from  both  parents,  after  exposure  to  cold  and  damp  while  travelling, 
presented  all  the  symptoms  of  diabetes.  She  was  rosy  and  robust.  At  the  age 
of  thirty  she  became  unduly  stout,  having  been  previously  spare  and  slim.  There 
had  been  decidedly  gouty  pains  in  the  feet  and  hands,  and  an  irritable  lichenous 
eruption  sometimes  appeared  on  the  arms.  Was  a  rather  large  eater,  and  par- 
took freely  of  potatoes.  Restricted  diet  caused  the  glycosuria  to  disappear  in  a 
short  time.  Occasional  gouty  attacks  in  minor  degree  oocurred.  Recrudescence 
of  glycosuria  three  years  subsequently,  followed  by  improvement  on  use  of  dietetic 
precautions.  Gradual  loss  of  weight  to  the  amount  of  eighteen  or  twenty  pounds 
durino-  this  period.  Muscular  power  enfeebled,  and  fatigue  sometimes  readily 
induced.  Occasional  deposits  of  lithates  in  the  urine.  Improvement  always 
secured  by  open-air  life,  with  exercise,  in  the  country.  Diuresis  not  copious, 
avera°inf  thirty  to  forty  ounces  daily  ;  no  thirst,  no  undue  appetite.  Karlsbad 
salt,  citrate  of  sodium,  nux  vomica,  and  Fowler's  solution,  at  intervals,  proved 
beneficial.  Absolutely  restricted  diet  badly  borne,  causing  disgust  and  anorexia. 
Digestion  always  improved  by  addition  of  some  amylaceous  food.  Sugar  not 
entirely  withheld.  Gradual  progress  of  mental  irritability  observed.  Case  now 
of  twelve  years'  duration,  glycosuria  continues,  the  sugar  varying  from  three  to 
seven  and  eight  per  cent.  Occasionally  the  U.  sanguinis  contains  most  sugar, 
and  sometimes  the  U.  cibi. 

Case  3. — C.  B.,  ast.  forty,  mother  of  four  children,  came  to  the  Hospital  suffer- 
ing from  glycosuria.    The  urine  was  acid,  of  specific  gravity  1.040,  highly  charged 


CASES   OF    GOUTY   DIABETES    AND    GLYCOSURIA.  399 

with  glucose,  and  free  from  albumen.  Diabetic  symptoms  for  four  months.  Her 
father  lived  to  be  seventy-three,  and  was  subject  to  "  rheumatism."  A  brother, 
aged  forty-one,  suffers  much  from  gout,  and  lost  a  daughter,  aged  six  and  a  half 
years,  from  diabetes. 

The  following  example  of  gouty  glycosuria  is  worthy  of  note, 
because  the  history  of  it  is  given  by  the  patient  himself,  a  country 
surgeon.      This  account  was  sent  to  me  in  1883  : — 

Case  4. — X.  Y.,  set.  thirty-six,  height  5ft.  9m.,  weight  I3st.  I2lbs.,  suffered  in 
early  years  from  chronic  bronchial  catarrh,  which  quite  left  at  sixteen.  About 
ten  years  since  had  several  joints  affected  with  "  rheumatic  gout." 

Mother,  a  great  invalid,  died  at  thirty-seven,  of  bronchitis  and  rheumatic 
arthritis  (?  gouty  bronchitis,  D.  D.). 

Father  died  suddenly  at  forty-seven  ;  was  an  accomplished  man,  and  the  best 
operator  in  this  part  of  the  country  ;  would  give  way  to  fits  of  alcoholic  intemper- 
ance, lasting  some  weeks,  and  then  again  would  strictly  abstain  for  months.  Had 
occasional  attacks  of  decided  podagra. 

Brother,  also  in  practice,  at  times  gouty. 

"  I  first  noticed  diabetic  symptoms  in  winter  or  early  spring  of  18S0 — thirst,  fre- 
quent desire  to  urinate,  and  amount  of  urine  passed  first  attracted  attention — 
sp.  gr.  at  that  time  1.042  ;  quantity  passed  in  twenty-four  hours  about  120 
ounces ;  sugar-reaction  well-marked  with  Moore's  and  Trommer's  tests.  At 
once  commenced  strict  abstention  from  starch  and  sugar,  with  the  result  that 
in  less  than  a  week  reaction  of  glucose  was  just  noticeable,  sp.  gr.  1.028,  quantity 
passed  sixty-eight  ounces.  Since  then  I  have  been  rather  careless.  I  live  well 
but  temperately,  play  cricket  a  good  deal  in  summer,  enjoy  life  generally,  and 
have  two  young  children.  At  the  present  time  sugar-reaction  is  well-marked,  sp. 
gr.  1.036,  quantity  ninety  ounces.  Am  not  dieting  at  all.  I  forgot  to  mention 
that  I  was  laid  up  last  winter  with  passage  of  an  uric  acid  renal  calculus." 

Six  years  later  he  wrote  : — 

"  I  feel  very  well,  occasionally  tired  from  overwork,  but  have  plenty  of  energy ; 
a  little  thirsty,  but  appetite  normal.  Sp.  gr.  of  urine  1.036,  sugar-reaction  well- 
marked  with  the  usual  tests,  and  acid ;  no  renal  calculi  since  I  left  Lincolnshire. 
I  have  a  little  gout  occasionally  in  my  toe,  tongue  clean,  bowels  very  regular ; 
desire  not  perhaps  quite  so  frequent,  but  vigour  unimpaired ;  sleep  well  at  night, 
and,  as  a  rule,  do  not  get  out  of  bed  to  pass  water  unless  I  have  supped  rather 
heavier  than  usual.  I  was  weighed  about  a  week  since,  and  was  then,  under  the 
same  clothing,  as  heavy  as  I  was  six  months  ago  ;  in  fact,  I  have  not  varied  for 
five  years — I2st.  21b. 

"  I  take  plenty  of  exercise,  doing  all  my  work  on  foot,  walking  from  two  to  eight 
miles  a  day,  with  an  occasional  longer  stretch.  I  am  now  aged  forty-two,  live 
temperately  but  well,  and  have  not  dieted  myself  for  the  last  six  years  beyond 
limiting  my  quantity  of  potatoes,  sweet  puddings,  and  wine.  Spirits  I  seldom 
touch,  but  have  a  pint  and  half  of  ale  in  the  day. 

"  I  may  as  well  mention,  in  fact,  I  think  it  important,  or  at  least  interesting,  that 
my  brother,  who  is  five  years  my  senior,  began  to  develop  glycosuria  about  four 
years  since  to  about  the  same  extent  as  myself.  He  has  a  large  country  practice, 
hunts  two  days  a  week,  and  although  he  drank  to  excess  at  one  time,  has  for  the 
last  six  years  been  a  strict  teetotaller.  He  also  has  had  occasional  attacks  of 
gout." 

Case  5. — Mr.  W.  B.,  set.  fifty -two,  brought  to  me  by  Mr.  Earle  of  Brentwood  in 
1880.  A  stout,  ruddy  man,  suffering  from  severe  eczema  almost  all  over  his  body, 
with  much  itching.     Occipital   headache  and  drowsiness  complained  of.     The 


4-00   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

action  of  the  heart  had  been  irregular  of  late.  Habits  alcoholic.  Is  very  thirsty. 
The  urine  was  of  specific  gravity  1.020,  and  contained  a  little  glucose.  Has  had 
no  regular  gout,  but  his  father  was  gouty,  and  was  alleged  to  have  died  of  the 
disease.  The  eczema  proved  obstinate  for  several  months.  Mr.  Earle  subse- 
quently informed  me  that  this  patient  often  passed  considerable  quantities  of 
sugar,  but  presented  no  ordinary  symptoms  of  diabetes.  He  was  then  in  fair 
health. 

Case  6. — A  lady,  set.  sixty-six,  seen  in  June  1S82  at  Milbrook  with  Mr.  Day- 
man. Arthritic  diathesis  well-marked.  Abdomen  obese.  Not  married  till  after 
fifty.  No  family.  Her  mother  was  the  twenty-eighth  child.  No  distinct  gouty 
history  in  the  family  (maternal  grandfather  possibly  gouty).  At  the  age  of  thirty- 
five  had  severe  iritis,  and  took  much  mercury.  The  iritis  was  considered  to  be 
rheumatic.  For  the  last  five  or  six  years  has  suffered  for  the  most  part  of  the  year, 
but  chiefly  in  winter,  from  pain  in  the  lower  dorsal  region.  At  first,  the  left 
side  was  affected,  then  both  sides.  There  is  extreme  tenderness  over  the  last  three 
ribs  on  each  side,  increased  by  pressure,  full  inspiration,  or  any  forced  move- 
ment. Can  only  walk  very  little  with  sticks.  No  crackling  on  flexing  the  joints, 
but  sometimes  snapping  is  felt  on  movement.  Three  months  previously  she  felt 
unusually  weak  and  ill,  and  was  thirsty,  and  the  urine  was  discovered  to  contain 
a  good  deal  of  glucose,  and  to  be  of  specific  gravity  1.040.  Rigid  diet  soon 
caused  removal  of  the  sugar  and  improvement  of  general  health.  Some  swelling 
and  pain  occurred  in  the  right  knee-joint  before  the  glycosuria  was  detected. 
The  urine  fell  in  specific  gravity  to  1.025.  The  dorsal  pain  became  worse.  No 
signs  of  organic  disease  of  the  spinal  chord  or  membranes,  nor  of  spondylitis 
or  aortic  aneurysm.  The  glycosuria  returned  with  slightly  relaxed  diet ;  the 
urine  contained  a  moderate  quantity  of  sugar  ;  specific  gravity  1.022.  The  urina 
sanguinis  contained  as  much  as  the  urina  cibi.  On  some  days  no  sugar  was  passed, 
and  none  would  appear  for  weeks.  Deposits  of  lithates  not  observed.  In  Septem- 
ber the  pain  almost  passed  away,  and  walking  became  possible.  Mr.  Dayman 
reported  (December)  that  this  improvement  had  continued.  "  The  urine,  examined 
every  few  weeks,  shows  traces  of  sugar.  All  fat  and  plumpness  are  gone.  She  has 
much  muscular  power,  can  walk  an}T  reasonable  distance,  and  expresses  herself 
as  'very  well.'  The  diet  is  partially  restricted,  and  cod  liver  oil  is  now  taken. 
She  has  lost  no  more  bulk  than  the  mere  absence  of  fat  would  account  for,  and 
this  loss  has  gone  on  pari  passu  with  the  decrease  in  the  glycosuria,  which,  I 
take  it,  is  a  point  in  the  patient's  favour,  being  the  reverse  of  what  happens  in 
phthisical  diabetes."     She  died  one  year  subsequently. 

The  following  cases  illustrate  grave  forms  of  diabetes  in  the 
sons  of  gouty  men  : — 

Case  i. — J.  M.,  apainter,  set.  thirty-six,  admitted  to  Mark  Ward,  November  1881. 
Has  suffered  from  diabetes  for  twelve  months,  and  been  passing  about  twenty 
pints  of  urine  daily  during  that  time.  He  has  had  colic,  but  has  no  blue  line  on 
the  gums.  He  has  xerodermia,  and  a  brother  has  also  this  affection.  His  father 
is  gouty.  He  himself  has  had  no  gouty  or  rheumatic  troubles.  The  urine  is 
of  sp.  gr.  1.034,  acid,  and  contains  abundance  of  glucose.  The  abdomen  has  been 
enlarging  for  three  months,  and  is  now  tense.  The  liver  does  not  appear  to  be 
tumid.     Has  not  been  submitted  to  any  anti-diabetic  treatment  hitherto. 

CASE  2. W.  K.,  a^t.  twenty-one,  a  waiter,  admitted  to  Mark  Ward,  March  1S82. 

Pallid,  poorly  nourished.     Always  temperate.     Subject  to  fainting  attacks  with 

giddiness but  no  loss  of  consciousness — about  once  a  month  for  greater  part 

of  his  life.    He  had  been  in  New  York  for  the  last  year,  but  felt  weak  and  unequal 


GOUTY    GLYCOSURIA.  40  I 

to  his  work  there.  Increase  of  appetite  and  thirst  observed  for  about  a  month, 
with  increased  flow  of  urine.  Has  wasted  much.  Has  been  subject  to  boils  for 
some  years.  Was  found  to  pass  eighteen  pints  of  urine  of  specific  gravity  1.035 
while  taking  extra  unrestricted  diet,  and  this  became  reduced  to  eight  pints.  On 
taking  regulated  diet,  he  passed  an  average  of  twelve  ounces  of  glucose  daily. 
No  physical  signs  of  disease  in  chest  or  abdomen.  His  parents  were  both  strongly 
arthritic.  The  father,  aged  sixty-eight,  had  twice  had  gout  in  his  feet  and  eczema 
of  the  right  arm.  He  was  a  hotel- waiter.  The  mother,  aged  seventy,  had  suffered 
from  rheumatoid  arthritis  for  fifteen  years.     (I  examined  them  both.) 

This  patient  chafed  under  anti-diabetic  diet,  and  made  his  escape  from  the 
Hospital. 

Dr.  Mahomed1  recorded  the  case  of  a  man,  set.  forty-two,  who 
had  had  gout  in  both  great  toes  two  years  previously,  and  who  pre- 
sented all  the  signs  of  granular  kidneys  with  cardio-vascular 
degenerative  changes.  The  father  died  at  eighty  years  of  age, 
"  asthmatic  ;  "  the  mother  was  living,  aet.  seventy,  with  dropsical 
legs,  and  two  brothers  had  died  of  diabetes. 

A  case  of  acute  diabetes  came  under  my  observation  in  a  man 
ast.  twenty-seven,  whose  father  was  gouty,  and  presented  tophi 
in  the  ears.  The  paternal  uncle  was  also  gouty.  There  was 
diabetes  in  one  of  the  cases  of  hgemorrhagic  retinitis,  reported  by 
Mr.  Hutchinson  in  his  communication  to  the  Clinical  Society,2  in 
a  man  set.  sixty-seven,  although  it  is  mentioned  that  there 
was  no  history  of  gout.  As  many  of  these  cases  occur  in  con- 
nection with  gouty  habit  of  body,  I  think  it  not  unlikely,  having 
regard  to  the  age  of  the  patient,  that  this  was  an  instance  of  gouty 
diabetes. 

The  following  case  is  of  particular  interest,  illustrating  the  co- 
existence of  acute  gout  with  persistent  glycosuria.  This  is,  in 
my  experience,  a  rare  event. 

H.  F.,  a  commercial  traveller,  jet.  fifty-four,  came  under  my  care  in  St.  Bartho- 
lomew's Hospital  on  November  10,  1888.  He  looked  ten  years  older  than  his  age, 
was  a  florid,  white-haired  man,  of  large  frame.  His  father  lived  to  seventy,  his 
mother  to  sixty-five.  His  maternal  grandmother  was  "  rheumatic,"  but  lived  to 
eighty.  A  brother  and  sister  died  of  phthisis,  one  brother  died  of  heart-disease, 
and  another  poisoned  himself  with  morphine. 

Fifteen  years  ago  he  began  to  be  diabetic.  Ten  years  ago  had  what  he  called 
"rheumatism."  Eight  years  ago  had  boils.  Two  weeks  ago  had  pains  in  right 
hip,  thigh,  and  swollen  right  knee  and  foot.  Six  days  ago  right  elbow  and  wrist 
swelled  and  were  very  painful.  On  admission,  the  right  wrist  and  hand  were  in 
a  state  of  gouty  inflammation.  His  tongue  was  red  and  "  beefy  ;  "  breath  "  dia- 
betic." Gums  retracted ;  teeth  large  and  strong.  Pulse  156,  of  good  volume  and 
tension.     Temperature  rose  on  the  1  ith  November  to  100.4°,  an(i  slight  febrile 


1  Guy's  Hospital  Reports,  1S81,  p.  373. 

2  Trans.,  vol.  xi.  p.  134,  1878. 

2  C 


402   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

movement  continued  till  the  iSth,  the  rise  occurring  at  night.  Afterwards,  sub- 
normal temperatures. 

Signs  of  pulmonary  emphysema.  Slight  cough.  Heart  a  good  deal  over- 
lapped. Epigastric  pulsation.  No  murmurs.  Sweated  freely.  Liver  and  spleen 
impalpable.  Urine  sp.  gr.  1.034,  glucose  15  per  cent.,  albumen  a  trace,  average 
quantity  119  ounces  for  first  four  days,  and  78  ounces  for  next  seven  days. 
Acetone  and  diethylacetic  acid  reactions.  He  had  lost  two  stones  in  weight  in 
the  last  two  years.  He  confessed  to  drinking  about  three  pints  of  beer  daily,  but 
no  spirit.  He  was  put  on  a  partially  restricted  diet ;  colchicum  and  citrate  of  potas- 
sium were  given,  and  belladonna  lotion  applied  to  the  gouty  wrist.  In  a  few  days, 
there  was  marked  relief  to  the  pains,  and  the  appetite,  which  was  not  lost,  in- 
creased. His  diet  was  improved,  and  bark,  nux  vomica,  and  citrate  of  sodium 
were  given  by  day,  and  colchicum  and  Dover's  powder  in  pill  at  night. 

On  the  23rd  November  he  was  out  in  the  Square,  and  his  pains  began  again  in 
the  wrist.  He  was  now  treated  with  sodium  salicylate  in  gr.xv.  doses  four  times 
a  day.  Dr.  Haig  made  some  analyses  of  the  urine  under  the  influence  of  this 
drug,  and  found  a  large  excretion  of  uric  acid  by  night,  with  a  small  out-put  of 
glucose,  and  a  large  excretion  of  glucose  and  small  one  of  uric  acid  by  day.  The 
excretion  of  urea  fell  as  that  of  uric  acid  increased.  The  patient  was,  however, 
very  unruly  and  odd  in  his  manner,  and  would  not  lend  himself  to  investigations 
of  an  exact  nature.  The  effect  of  the  salicylate  was  marked  in  causing  free 
excretion  of  uric  acid. 


Patients  suffering  in  this  manner  cannot,  and  must  not,  be 
treated  as  for  ordinary  diabetes.  They  crave  for  theoretically 
contra-indicated  food,  and  languish  if  it  be  denied,  and  are  worse 
if  they  submit  to  restricted  diet.  Like  other  diabetics,  they  will 
often  break  through  any  enforced  rules,  and  deceive  the  physician. 
This  man  would  doubtless  have  been  much  benefited  by  continued 
treatment  with  salicylate  of  sodium  and  a  carefully  arranged  diet, 
but  he  preferred  to  go  out  of  the  Hospital. 

Salicylate  of  sodium  may  be  given  in  cases  of  gouty  glycosuria 
in  doses  of  fifteen  grains  thrice  daily,  the  urine  being  examined 
quantitatively  for  glucose.  If  no  marked  benefit  ensues  within  a 
few  days  of  this  treatment,  it  is  not  likely  to  prove  useful  in  any 
case.  Aperients  containing  mercury,  given  at  intervals,  are  certainly 
useful.  Opium  and  codeia  are  unsuitable  in  all  but  the  worst 
and  aggravated  cases.  The  amount  of  sugar  in  the  urine  has 
been  found  to  be  increased  after  taking  sodium  sulphate. 

The  symptoms  of  most  evil  import  in  these  cases  are  those 
indicating  cardiac  failure,  general  loss  of  nerve-power  and  tone, 
loss  of  weight,  due  to  disappearance  both  of  muscle  and  fat,  and 
impairment  of  appetite.  There  are  to  be  observed  distinct  periods 
in  which  the  disorder  is  aggravated,  all  its  symptoms  being 
prominent,  and  others  in  which  improvement  occurs,  weight  is 
recovered,  and  the  general  health  in  a  measure  restored.  Albu- 
minuria is   always   a    grave    symptom,      Acetonuria    and   loss   of 


INTERSTITIAL    NEPHRITIS.  403 

knee-jerks  may  long  precede  the  onset  of  more  serious  symp- 
toms.1 Coma  may  be  the  last  event,  and  is  not  so  infrequent  in 
this  class  of  cases  after  the  age  of  thirty-five  as  the  statistics 
of  Dreschfeld  would  lead  one  to  believe.2  Cataract  is  not  observed 
with  any  frequency  in  this  class  of  diabetics,  and  the  same  may 
certainly  be  affirmed  of  pulmonary  phthisis. 

It  is  worthy  of  note  that  the  Hebrew  race  appears  to  be 
prone  to  glycosuria,  especially  amongst  its  wealthy  classes. 

Many  of  the  adipose  patients  lose  a  good  deal  of  their  fat, 
but  it  is  not  desirable  to  pursue  any  dietary  or  method  that  is 
rapidly  weight-reducing.  No  sudden  or  violent  measures  can  be 
sanctioned. 

The  patient's  weight  should  be  taken  at  regular  intervals  and 
duly  recorded.  So  long  as  weight  is  retained,  there  is  little  likeli- 
hood of  grave  symptoms  arising. 

Genito-Urinary  System. 

Gouty  Interstitial  Nephritis.— The  gouty  affections  involving  the 
urinary  tract  are  numerous.  The  condition  of  the  kidneys  in 
respect  of  cirrhosing  lesion  has  been  already  dwelt  on  at  some 
length,  and  stress  laid  on  the  importance  of  duly  recognizing  its 
presence  both  in  early  and  advanced  stages.  All  forms  of  treat- 
ment for  the  gouty  must  be  regulated  with  reference  to  the  existing 
renal  condition,  and,  hence,  care  must  be  taken  in  prescribing  both 
dietetic  and  medicinal  measures,  especially  as  regards  nitrogenous 
food  and  the  employment  of  drugs,  such  as  opium,  colchicum,  or 
sodium  salicylate.  The  influence  of  climate  is  very  marked  in 
these  cases,  and  renal  fibrosis  may  be  materially  checked  in  its 
course  by  combined  attention  to  diet,  and  recourse  to  warmer 
surroundings  in  winter-time.  Renal  adequacy  is  to  be  gauged 
by  observation  of  the  amount  and  density  of  the  urine  passed, 
especially  where  there  is  little  or  no  albuminuria.  The  percentage 
of  urea  should  be  estimated  at  intervals,  and  persistent  out-put  of 
less  than  two  per  cent,  should  excite  serious  attention  in  any  case. 
The  diet  should  consist  mainly  of  fish,  vegetable  and  farinaceous 
food.  Milk-diet  is  sometimes  very  serviceable  for  periodic,  or, 
when  it  can  be  borne,  for  continuous  employment.  Butcher's 
meat  and  alcohol  are  to  be  avoided  as  a  rule,  or  very  sparingly 
taken.  The  condition  of  the  patient  rather  than  the  nature  of 
his  ailment  demands  attention  in  every  case.     Arsenic,  strychnine, 

1  S.  West,  Proc.  Roy.  Med.  Chir.  Soc,  November  1888. 

2  Bradshawe  Lect.  Roy.  Coll.  of  Physicians,  18S6. 


404   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

and  the  mineral  acids  are  often  valuable,  especially  when  iron  is 
contra-indicated  or  ill  borne.  Frequency  of  micturition  at  night 
in  elderly  persons  with  granular  kidneys  may  be  treated  by 
bromides  or  monobromated  camphor,  and  the  amount  of  fluid 
taken  in  the  later  part  of  the  day  should  be  restricted. 

Paraldehyde  in  half-drachm  doses  is  serviceable  in  cases  of 
dilated  and  labouring  heart  in  these  cases.  The  headaches  so 
commonly  experienced  are  susceptible  of  relief  by  nitro-glycerine 
tablets  (gr.  1/100)  taken  three  or  four  times  daily.  Urasmic 
convulsive  states  are  best  treated  with  five-grain  doses  of  hydrate 
of  chloral  every  two  hours,  beginning  perhaps  with  a  larger  dose. 
Sheltered  winter  climates  should  be  sought,  and  Algiers  is  one  of 
the  most  favourable  of  these. 

Renal  Calculi. — The  main  lines  of  treatment  relate  to  free  dilu- 
tion of  the  blood  and  the  consequent  diuretic  action  thereby 
induced.  Alkaline  medication  is  important,  and  is  best  employed 
by  prolonged  use  of  these  agents  in  diluted  form.  The  most 
significant  indications  of  renal  calculi  are  attacks  of  ureteric  spasm ; 
but  in  many  cases,  stones  may  be  lodged  in  the  kidneys  which 
show  no  tendency  to  pass  away,  and  declare  their  presence  by 
localized  pain  and  hasmaturia,  more  or  less  grave  and  continuous. 
Little  benefit  is  derivable  from  drugs  in  such  cases.  Rest  is  very 
important.  A  dietary  suited  to  the  patient's  general  and  dyscrasic 
condition  must  be  enforced,  and  diluents  must  be  freely  exhibited. 
Barley-water  or  linseed  infusion  and  skimmed  milk  may  be  given, 
but  it  is  best  to  employ  distilled  water  to  the  extent  of  three  or 
four  pints  in  the  day  if  recourse  cannot  be  had  to  some  appro- 
priate Spa.  Citrate  of  potassium  is  of  value,  and  citrate  of  lithium 
taken  freely  diluted.  The  bowels  should  be  regulated  by  Fried- 
richshal  or  Ptillna  water.  The  best  results  are,  however,  to  be 
gained  from  a  course  of  treatment  by  water- drinking  at  Buxton, 
Bath,  or  Malvern  in  this  country,  or  at  Oontrexeville  or  Vittel,  near 
the  Vosges  Mountains.  Large  quantities  of  these  waters  are 
commonly  necessary  to  ensure  solution  and  dispersion  of  the  cal- 
culi. It  is  noteworthy  that  the  waters  of  the  two  latter  stations 
are  rich  in  lime  salts,  which  would  theoretically  appear  to  be 
contra-indicated  in  calculous  disorders,  but  the  results  of  their 
employment  are  unquestionably  satisfactory,  calculi  and  masses  of 
uratic  concretions  being  expelled,  with  cessation  of  the  exhaust- 
ing hgematuria,  and  complete  relief  to  the  patients.  Baths  and 
douches  to  the  loins  also  aid  the  expulsion  of  calculi  and  gravel. 
These  waters  are  portable,  but  it  is  difficult,  if  not  practically 
impossible,  to  conduct  the  treatment  satisfactorily  away  from  the 


RENAL    COLIC.       VULVAR    PRURITUS.  405 

Spas.      In  the  case  of  large  calculi,  the  patient  must  submit  to 
several  courses  of  treatment  in  the  above  fashion. 

Chronic  cystitis,  either  gouty  or  calculous,  is  capable  of  great 
amelioration  and  cure  at  Contrexeville  and  Vittel. 

Renal  Colie. — Renal  and  ureteric  spasm  due  to  passage  of  cal- 
culi demands  ordinary  treatment — opium,  belladonna,  henbane, 
or  chloral,  or  morphine,  subcutaneously,  being  employed,  together 
with  hot  stupes  and  hot  hip-baths. 

Vesical  Calculi. — Vesical  calculi,  if  not  removed  by  diluents, 
demand  crushing  or  cutting  operative  procedures.  Tendency  to 
calculous  formation  may  be  averted  by  early  recourse  to  Carlsbad 
water -treatment,  or  by  the  steady  use  of  any  of  the  bitter  saline 
waters  taken  each  morning. 

Balanitis. — Balanitis  is  best  treated  by  warm  fomentations, 
followed  by  the  application  of  equal  parts  of  starch  and  boric 
acid,  a  piece  of  dry  lint  being  inserted  under  the  prepuce. 
Boi'oglyceride  lotion  is  useful. 

Vulvar  Pruritus. — Vulvar  pruritus  is  often  very  intractable.  It 
is  most  often  associated  with,  if  not  directly  dependent  on,  glycos- 
uria. Sponging  with  hot  water,  or  carbolic  acid  lotion,  one  to 
forty,  is  sometimes  efficacious.  Boi'oglyceride  (pure)  or  boric 
acid  ointment  may  be  used  after  hot  fomentation.  Calomel  oint- 
ment, two  drachms  to  the  ounce,  is  of  good  service,  followed  by 
dusting  of  the  parts  with  a  powder  composed  of  one  drachm  of 
camphor  and  four  each  of  oxyde  of  zinc  and  starch.  Goulard 
extract,  one  drachm,  and  milk,  two  ounces  (lactate  of  lead),  or 
cocaine  ointment  may  prove  useful.  The  applications  may  have 
to  be  changed  before  relief  is  afforded.  Compound  tincture  of 
benzoin  is  efficacious  as  a  local  application. 

The  general  condition  of  which  the  pruritus  is  the  expression 
must  be  met  by  appropriate  treatment. 

Affections  of  the  Penis.— I  have  already  alluded  to  persistent 
priapism  as  a  symptom  in  certain  cases  of  gouty  habit.  It  may 
affect  elderly  men,  and  prove  annoying  at  night.  Alkaline  treat- 
ment and  bromide  of  potassium,  with  carefully  regulated  diet,  are 
generally  efficacious  to  remove  this. 

Fibrous  thickening  of  the  sheath  of  the  corpus  cavernosum  may 
occur,  producing  irregularities  on  erection,  firm  masses  being  felt  in 
the  septum  or  on  other  parts  of  the  penis.  Chordee  may  occur  in 
consequence.  Paget  has  described  a  general  gouty  inflammation 
of  the  whole  organ,  causing  enlargement,  but  not  the  hardness,  of 
erection. 

Thrombosis  in  Penis. — Thrombosis    may  occur    spontaneously 


406   TEEATMENT  OF  THE  SEVEKAL  VARIETIES  OF  GOUT. 

in  the  corpus  cavernosum  after  the  fashion  of  gouty  phlebitis. 
One  or  more  hard  nodules  of  the  size  of  a  pea  or  bean  may  be 
felt,  and  they  may  prove  painless  even  on  pressure,  and  remain 
for  a  long  period,  slowly  becoming  smaller.  Little  is  indicated  in 
the  way  of  local  treatment.  The  unguentum  iodi  may  be  rubbed  in, 
and  any  overt  gouty  indications  be  treated  on  general  principles. 
Herpes  Praeputialis. — In  the  gouty  there  is  more  than  ordinary 
tendency  for  herpes  to  occur  on  the  prepuce.  Some  forms  of 
balanitis  are  herpetic.  There  is  tendency  to  recurrence,  and  pure 
coitus  may  be  an  excitant.  Zinc  ointment,  with  carbolic  acid  in 
the  proportion  of  half  a  drachm  to  the  ounce,  or  boric  acid  oint- 
ment, are  suitable  applications. 

Orchitis. — Orchitis  is  sometimes  distinctly  a  manifestation  of 
acute  gout.  It  may  be  a  phase  of  retrocedent  gout,  or  suddenly 
set  in  after  minor  gouty  premonitions  in  other  parts. 

Treatment  consists  in  supporting  the  testicle  by  adjusted 
padding.  Lead  and  opium  lotion  should  be  applied  hot  at  fre- 
quent intervals,  or  equal  parts  of  glycerine  and  belladonna  extract 
may  be  freely  painted  over  the  scrotum.  A  mercurial  purgative 
should  be  administered,  and  the  bowels  kept  freely  open.  Col- 
chicum  with  iodide  and  bicarbonate  of  potassium  is  very  efficacious. 
Rest  is  imperative,  and  a  light  dietary.  The  enlargement  may 
remain  for  many  weeks,  with  some  induration  of  the  epididymis. 
There  may  be  some  fluid  effused  at  first  into  the  tunica  vaginalis. 
Atrophy  of  the  organ  is  not  apt  to  supervene. 

Vesical  Haemorrhage. — Vesical  hgemorrhage  has  been  already 
discussed.  It  demands  little  or  no  treatment.  Clots  may,  how- 
ever, have  to  be  withdrawn  from  the  bladder  by  means  of  a  large- 
eyed  catheter,  and  by  suction. 

Cystitis. — Cystitis  is  sometimes  very  severe,  and  calls  for  treat- 
ment by  restricted  "  slop  "  diet,  diluents,  especially  milk,  and  hot 
belladonna  fomentations  or  poultices  to  the  hypogastrium.  Meta- 
stasis of  eczema  from  the  skin  may  occur,  and  an  enanthematous 
cystitis  supervene.  Citrate  of  potassium,  or  liquor  potassge,  with 
henbane,  given  in  infusion  of  buchu  or  decoction  of  pareira  brava, 
are  useful,  and  opium  or  belladonna  may  be  employed,  if  required. 
Decoctions  of  barley,  linseed,  or  triticum  repens,  with  liquorice, 
are  useful  as  diet-drinks.  Rest  in  a  warm  bed  is  essential,  and 
hot  hip-baths  at  the  bedside  may  be  used  twice  daily.  Colchicum 
may  be  given  at  night  with  Dover's  powder  in  pill,  and  a 
mercurial  purge,  followed  by  a  saline  cathartic,  will  prove  of 
value  at  intervals. 

Urethritis — Prostatic  Gout. — Gouty  urethritis,  which  often  simu- 


OVARITIS.       CONGESTIVE    DYSMENORRHEA.  407 

lates  gonorrhoea,  and  prostatic  gout,  demand  similar  treatment — 
rest,  light  diet,  and  sandal-wood  oil  proving  useful.  Hot  hip- 
baths are  very  soothing. 

If  the  attacks  in  the  bladder,  prostate,  or  urethra  are  due  to 
retrocedency  from  a  gouty  joint,  efforts  may  be  made  to  reinduce 
the  arthritis.  In  severe  and  sthenic  cases,  half  a  dozen  leeches 
may  be  applied  to  the  perineum,  followed  by  fomentation. 
Tartar  emetic  in  small  doses,  with  opium,  may  prove  of  service 
in  these  cases,  and  aperients  are  called  for.  Retention  of  urine 
must  be  relieved,  if  necessary,  by  a  soft  rubber  catheter. 

Ovaritis. — Ovaritis  calls  for  rest  in  bed  and  hot  poultices  or 
stupes  with  compound  camphor  or  belladonna  liniment.  Colchi- 
cum  and  alkalies  with  moderately  strong  aperients  are  useful. 

Recumbency  is  imperative  till  all  pain  is  past,  and  it  is  well 
to  continue  this  till  the  next  catamenial  flow  has  subsided.  A 
fly-blister  over  the  region  of  the  affected  ovary  is  sometimes 
useful,  and  may  have  to  be  repeated.  Belladonna  and  other 
anodyne  pessaries  are  also  serviceable. 

Congestive  Dysmenorrhcea— Ovarian  and  Pelvic  Neuralgia. — The 
gouty  habit  predisposes  to  menstrual  suffering.  There  may  be, 
with  hysterical  tendency,  ovarian  neuralgia  or  uterine  pain  alter- 
nating with  other  neuralgic  manifestations. 

Exposure  to  cold  and  damp  is  to  be  carefully  avoided  in  these 
cases.  Saline  aperients  are  of  use.  Pain  may  be  relieved  by 
cannabis  indica,  sumbul,  and  bromide  of  potassium.  Antipyrin 
is  also  very  serviceable  in  ten  or  fifteen  grain  doses.  In  atonic 
cases,  guaiacum  thrice  a  day  is  sometimes  useful,  partly  perhaps 
by  its  laxative  action.1  Ten  grains  of  powdered  guaiacum  with 
as  much  carbonate  of  magnesium  may  be  given  each  morning. 
This  prescription  is  especially  useful  where  shreds  of  membrane  or 
clots  are  discharged.  Warm  hip-baths  should  be  taken  nightly. 
The  employment  of  alcoholic  stimulants  and  sedatives  by  the 
patient  herself  must  be  sedulously  guarded  against.  Henbane, 
with  musk  or  valerian,  may  be  given  with  quinine  for  neuralgia 
in  the  pelvic  region,  and  arsenic,  with  alkalies,  is  also  advisable  in 
some  cases. 

Much  benefit  is  to  be  secured  for  patients  suffering  from  these 
ailments  by  recourse  to  certain  spas.  In  this  country,  Buxton, 
Bath,  and  Harrogate  are  available ;  on  the  Continent  of  Europe, 
Vichy,  Schlangenbad,  Ems,  Wiesbaden,  Baden-Baden,  Marienbad, 
and  Carlsbad  are  amongst  the  most  suitable  either  for  baths,  or 
for  combined  use  of  these  with  water-  drinking. 

1  Recommended  by  the  late  Dr.  Rigby  of  St.  Bartholomew's  Hospital 


408   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

Gouty  Affections  of  the  Eye. 

Arthritic  Ophthalmia. — For  special  methods  of  treatment  of 
arthritic  ophthalmitis,  iritis,  irido-cyclitis,  retinal  haemorrhages, 
episcleritis,  and  glaucoma,  I  must  refer  the  reader  to  works  on 
ophthalmic  surgery.  I  would  only  mention  in  this  place  that 
the  gouty  habit  of  body  demands  at  all  times  appropriate  treat- 
ment whenever  any  local  manifestations  of  it  appear.  Mercury, 
quinine,  aconite,  colchicum,  iodide  of  potassium,  and  alkalies  are 
the  best  medicinal  agents  for  internal  use.  Locally,  collyria  of 
borax  or  lead  subacetate,  applied  warm,  with  a  four  per  cent, 
solution  of  cocaine,  if  there  is  much  pain,  leeches  to  the  nares 
or  temples,  and  atropine  to  maintain  pupillary  dilatation,  are 
proper  remedies.  A  shade  must  be  worn.  Purgation,  hot  pedi- 
luvia,  and  rest  in  a  darkened  room  are  all  advantageous  for  acute 
arthritic  ophthalmic  disorders. 

It  is  noteworthy  that  these  troubles  are  much  influenced  by 
season  and  climate,  being,  for  reasons  which  are  not  far  to  seek, 
most  apt  to  occur  in  spring  and  autumn. 

Integumentary  System. 

Gouty  Skin-Diseases. — Successful  treatment  of  skin-disorders 
dependent  on  gouty  habit  of  body  demands  much  attention  and 
skill.  It  is  impoi'tant  to  recognize  their  connexion  with  this 
dyscrasia,  and  as  important  to  refer  skin-diseases  not  so  dependent 
to  their  proper  category.  In  many  instances,  there  is  no  history 
of  articular  gout  in  the  patient,  but  the  family  history  and  per- 
sonal proclivities  afford  the  clue,  if  carefully  sought. 

The  lines  of  treatment  are  both  local  and  constitutional. 
Many  of  these  disorders  tend  to  recur  from  time  to  time  as  does 
articular  gout,  and  they  are  often  exceedingly  vexatious  to  the 
patient,  and  sometimes  very  difficult  to  treat  effectually.  In 
some  cases,  it  is  well  not  to  treat  these  disorders  too  actively,  and 
to  recognize  that  they  are  a  lesser  evil  than  others  which  might 
ensue  were  they  suppressed.  Some  are  acute  and  of  sudden 
evolution, — metastatic  outbursts;  others  are  very  chronic,  persist- 
ing for  months  and  years. 

Pruritus. — This  is  sometimes  very  rebellious  to  all  forms  of 
treatment,  and  occasionally  incoercible.  I  have  known  instances 
in  gouty  old  men  to  persist  more  or  less  for  years.      Accurate 

1  A  good  collyrium  is  the  following  : — R  Cocaine  gr.i.,  Atropines  Sulphatis  gr.iij., 
Aq.  Rosse  f§i.     Solve.      (Atropine  is  to  be  avoided  if  there  is  any  plus  tension  in  the 

eyeball.) 


SKIN-DISEASES.       PUU15ITUS.  409 

diagnosis  is  of  importance,  and  the  absence  of  prurigo  due  to 
pediculi  must  be  assured.  No  skin-lesions  may  be  apparent,  but 
some  papules  may  be  excited  around  hair-follicles  by  constant 
scratching. 

Errors  in  diet  must  be  corrected ;  rich  dishes,  sugar,  acids, 
fruits,  and  acid  vegetables  abstained  from,  likewise  all  wines,  not 
excepting  that  of  Bordeaux.  A  little  whisky  and  water  is 
allowable.  Sherry  is  particularly  harmful.  Occasional  mercurial 
aperients  and  alkalies  may  be  given  with  advantage,  and  a  pint 
of  Vichy,  lithium,  or  other  alkaline  water  taken  daily  with  food. 

Locally,  warm  alkaline,1  sulphur,2  or  bran  baths 3  (the  bran 
being  placed  in  a  muslin  bag),  are  proper  every  second  or  third 
day.  Fine  cotton  or  silk  underclothing  covered  by  flannel  or 
merino,  according  to  the  time  of  year,  is  desirable  rather  than 
flannel  worn  next  the  skin. 

Lotions  of  borax  or  of  carbolic  acid  (f5ij.  ad  oi.),  used  hot,  are 
often  soothing.  Tincture  of  benzoin  may  be  painted  over  any 
very  irritable  places.  Bromides  and  cannabis  indica  may  be 
given  to  secure  rest  at  night,  if  required.  Zinc  ointment  with  a 
drachm  of  powdered  camphor,  or  of  carbolic  acid,  to  each  ounce  is 
useful,  and  should  be  frequently  applied  ;  or  an  ointment  composed 
of  a  drachm  of  oil  of  cade  to  an  ounce  of  vaseline  may  be  rubbed 
in.  A  course  of  waters  at  Homburg  or  Kissingen,  or  the  baths 
of  Schlangenbad  may  be  tried.  Where  any  signs  of  debility  are 
present,  mineral  acids  with  bark  and  strychnine  are  useful,  and 
arsenic  may  be  employed  as  a  suitable  tonic.  The  treatment  of 
pruritus  vulvae  I  have  already  discussed  (p.  405). 

Pruritus  Ani. — Warm  alkaline  or  carbolic  lotions  are  useful, 
and  so  is  ferric  sulphate  lotion  (gr,  ij.  ad  f  31.).  Dusting  powders 
of  bismuth  carbonate,  boric  acid,  talc,  fuller's  earth,  or  zinc 
carbonate  should  be  freely  used  after  bathing.  Any  associated 
hemorrhoidal  tendency  or  indications  of  portal  venous  congestion 
demand  mercurial  aperients  and  restricted  diet,  soups  and  wines 
being  especially  abstained  from.  Sulphur  in  the  form  of  an  elec- 
tuary, or  Garrod's  compound  sulphur  lozenge,4  is  often  very 
serviceable  in  this  disorder.  Half  a  drachm  of  the  former,  or  one 
or  two  lozenges  may  be  taken  at  bedtime  for  a  week  or  two. 

Furuneuli-Anthrax. — In  these  disorders  the  condition  of  the 
urine  should  be  ascertained.      Glucose  and  albumen  may,  or  may 

1  Sodii.  Bicarb.  3iv.,  Aq.  cong.  xxx.  96°  F. 

2  Potassse  Sulphurate  §viij.,  Aq.  cong.  xxx.  96°  F. 

3  Furfuris  lb. v.,  Aq.  cong.  xxx.  960  F. 

4  R  Lactis  Sulphuris  gr.v.,  Potass.  Tart.  Addas  gr.i.  ft.  Trochiscus  secundum  artem. 


4-IO   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

not,  be  present  in  it.  Sodium  salicylate  with  cinchona,  calcium 
sulphide  (gr.  £  quater  die),  fresh  yeast  in  ounce-doses  thrice 
daily,  or  quinine  with  mineral  acids  may  be  tried,  if  necessary,  in 
succession  for  recurrent  boils.  A  piece  of  belladonna  plaster  or 
liniment  of  iodine  painted  around  each  furuncule  is  sometimes 
soothing  and  abortive,  and  so  is  a  saturated  solution  of  boric  acid. 
When  the  boils  point,  they  may  be  opened  with  a  carbolized 
lancet,  and  dressed  with  iodoform  or  resin  ointment.  Poulticing 
is  objectionable. 

In  the  treatment  of  carbuncle,  which  is  a  disorder  of  middle 
or  advanced  life,  especially  in  persons  of  gouty  habit,  supporting, 
but  not  stimulating,  diet  is  called  for.  Alcohol  is  best  avoided 
unless  there  is  prostration.  Milk-diet  is  best.  Poulticing  is  now 
commonly  disapproved,  and  applications  of  belladonna  extract 
with  glycerine,  in  equal  parts,  preferred.  When  the  surface 
becomes  cribriform  and  discharges,  resin  or  iodoform  ointment 
may  be  applied.  Opinions  now  differ  as  to  incising  carbuncles. 
In  some  cases  it  may  be  necessaiy  to  practise  incisions,  and  the 
risk  of  this  is  probably  less  than  in  former  times  before  antiseptic 
surgery  had  won  its  triumphs.  Bark  and  ammonia,  quinine,  iron, 
and  mineral  acids,  with  wine,  will  be  useful  during  discharge 
of  sloughs,  and  as  convalescence  proceeds.  In  cases  of  chronic 
glycosuria  carbuncle  may  prove  very  dangerous  and  fatal. 

Psoriasis. — Treatment  relates  to  the  acute  and  the  chronic 
forms  of  the  disorder.  In  the  former,  there  is  not  much  to  be 
expected  from  local  or  any  other  treatment  in  the  first  instance. 
Saline  aperients  with  alkalies  and  colchicum  are  of  most  service,1 
and  if  there  is  any  general  plethora,  mercurial  purges  may  be 
given  at  intervals.  The  diet  must  be  strictly  regulated,  so  as  to 
ensure  as  little  acid- formation  as  possible  in  the  system.  Local 
treatment  at  first  is  best  confined  to  simple  anointing  with 
almond  oil  or  spermaceti  ointment.  Afterwards,  mild  tarry 
ointments,  as  oil  of  cade  (5ij.  ad  ^i.  of  simple  ointment  or  soft 
paraffin,  or  the  same  proportion  of  liquor  carbonis  detergentis  and 
soft  paraffin)  or  chrysophanic  acid  (gr.x.  ad  31.)  may  be  rubbed  in, 
alkaline  baths  being  taken  thrice  a  week.  When  fresh  patches 
cease  to  appear,  arsenic  may  be  begun,  four  minims  of  Fowler's 
solution  or  of  the  liq.  sodii  arseniatis  being  given  with  sodium,  or 
potassium  bicarbonate,  and  nux  vomica.  Vichy,  La  Bourboule, 
or  Boyat  water  may  be  taken  with  meals. 

Obstinately  persisting  patches  should  be  rubbed  with  liquor 

1  R.  Potassii  Nitratis  gr.x.,  Potassii  Bicarb,  gr.xx.,  Magnesii  Sulph.  oi-,  Tree.  Sem. 
Colchici  nixv.,  Aq.  Menth.  Pip.  ad  f5i.     M.  ft.  haustus  ter  die  sumendus. 


PSORIASIS.       ECZEMA.  4  I  I 

potassae,  well- washed  subsequently,  and  smeared  with  equal  parts 
of  zinc  and  pitch  ointment.  Sometimes,  no  treatment  avails  to 
remove  these  patches,  and  they  are  then  better  left  alone.  They 
subside  occasionally,  and  other  gouty  phases  appear — in  the 
bladder  by  metastasis  from  the  legs,  and  in  the  thoracic  viscera 
by  retrocedence  from  the  trunk. 

A  hydrotherapeutic  course  at  the  Spas  is  sometimes  answerable 
for  a  removal  of  psoriasis  and  an  induction  of  arthritis. 

Care  is  required  in  treating  psoriasis  in  persons  suffering 
from  bronchitis  with  pulmonary  emphysema,  since  congestion  and 
haemoptysis  may  replace  the  less  grave  disorder. 

These  alternations  of  process  are  sometimes  very  noteworthy  in 
sufferers  both  from  psoriasis  and  chronic  eczema. 

The  sulphur  waters  of  Harrogate  and  other  Spas  are  very  useful 
for  the  treatment  of  gouty  psoriasis. 

Eczema. — Eczema  demands  treatment  for  the  acute  and  the 
chronic  form.  The  former  is  best  conducted  on  the  lines  already 
laid  down  for  the  treatment  of  acute  psoriasis  in  respect  of  consti- 
tutional and  dietetic  measures.  Ointments  or  lotions  may  be 
used  as  preferred.  The  severe  burning  and  itching  of  the  early 
stages  is  best  mitigated  by  zinc  ointment,  with  camphor  or  car- 
bolic acid,  the  parts  being  lightly  covered  up.  The  daily  bath 
must  be  given  up  if  the  trunk  or  extremities  are  involved.  Wash- 
ing must  be  less  frequent,  warm  rain,  or  distilled,  water  and  thin 
gruel  or  starch  decoction  being  used,  and  no  soap.  Soft  diaper 
towels  should  be  employed,  and  the  parts  thoroughly  dried  and 
quickly  anointed  afterwards.  Many  cases  are  prevented  from  heal- 
ing because  the  affected  parts  are  too  often  uncovered  and  washed. 

Useful  ointments  are  the  unguentum  calamina?,  unguentum 
acidi  borici,  unguentum  zinci  oleatis,  and  the  unguentum  glycerini 
plumbi  subacetatis.  It  is  of  the  last  importance  for  successful 
treatment  to  have  these  freshly  prepared  whenever  possible.  Stale 
and  rancid  preparations  are  worse  than  useless.  Carbonate  of 
bismuth.  3i.  ad  Ji.,  is  a  very  useful  preparation,  and  so  is  pre- 
cipitated chalk  ointment  of  the  same  strength.  Pasty  lotions  of 
calamine,  zinc  oxyde,  with  glycerine  and  lime-water,  are  available, 
but  for  efficient  employment  demand  care  on  the  part  of  the 
nurse  and  patient.  Boric  acid  in  impalpable  powder  is  sometimes 
very  serviceable,  and  should  be  dusted  on  the  patches  with  a 
powder-puff. 

After  the  acute  stage  has  passed  off,  washing  with  soap  may  be 
practised,  good  Castile  soap  being  the  best  to  employ,  and  the 
ointment  or  lotion  reapplied  for  a  term. 


412   TREATMENT  OF  THE  SEVERAL  VARIETIES  OF  GOUT. 

The  too  common  resort  to  arsenical  medication  in  these  cases  I 
believe  to  be  unavailing,  or  perhaps  worse ;  alkalies  with  some 
bitter  tonic  being  more  effectual. 

A  hyclrotherapeutic  course  at  Ems,  Schlangenbad,  Wildbad,  or 
Royat,  with  some  mild  alkaline  or  aperient  drinking-water,  is 
often  of  use  to  restore  health.  Arsenic  is  available  in  later 
stages,  or  where  the  eczema  shows  tendency  to  persist.  It  may 
then  be  given  with  alkalies,  or  taken  in  the  form  of  La  Bourboule 
water  on  the  spot. 

Certain  local  patches  of  eczema  demand  special  treatment. 
That  affecting  the  ears  is  benefited  sometimes  by  glycerine  of 
tannin,  or  by  mild  nitrate  of  mercury  ointment.  Compound 
tincture  of  benzoin  will  help  to  heal  others.  The  unguentum 
hydrargyri  subchloridi  (gr.  lxxx.  ad  fy\.)  is  sometimes  useful  for 
eczema  affecting  the  perineum  and  for  pruritus  ani.  Chronic 
eczema  in  the  dry  form  demands  similar  treatment  to  that  avail- 
able for  patches  of  psoriasis,  but  there  is  often  difficulty  in 
securing  full  measure  of  relief.  Many  cases  will  only  yield  to 
vigorous  internal  treatment  combined  with  local  applications, 
and  sometimes  little  good  comes  till  mercury  and  colchicum  are 
employed.      Persistent  errors  of  diet  must  be  corrected. 

Change  of  scene  and  climate  is  often  helpful  in  chronic  cases. 
Harrogate  is  a  valuable  resort  both  for  its  summer  climate  and 
its  waters.  The  inland  air  and  influences  of  the  European 
Continent  sometimes  avail  much  when  drugs  and  British  health- 
resorts  fail  to  bring  relief.  Sea-air  and  influence  are  particularly 
noxious  for  this  class  of  patients,  and  it  is  difficult  to  get  beyond 
these  influences  anywhere  in  these  islands.  Hard  waters,  both  for 
internal  and  external  use,  are  always  harmful  in  eczema. 

Caution  must  be  exercised  in  treating  cases  of  inveterate 
eczema  in  such  gouty  persons  as  are  subject  to  visceral  compli- 
cations. If  such  occur  during  treatment,  the  eczema  must  be 
neglected  forthwith,  and  efforts  be  made  to  induce  regular  arthritic 
gout  at  a  distant  part. 

Urticaria Urticaria  demands  alkaline  treatment.     Magnesium 

and  sodium  salts,  with  colchicum,  are  amongst  the  best  remedies. 
Persistent  tendency  to  this  disorder  is  sometimes  cut  short  by  an 
emetic  of  ipecacuanha. 

Locally,  lead  and  opium  lotion  or  lactate  of  lead  afford  most 
certain  relief.  Any  idiosyncrasies  with  respect  to  food  as  direct 
provocatives  must  be  guarded  against.  Eczema  may  co-exist 
with  urticarial  tendency,  causing  a  very  teasing  disorder. 

Herpes. — The   several  varieties   of  herpes  vary  in  importance, 


GOUTY    CACHEXIA.  413 

and,  indeed,  in  significance,  according  to  the  locality  implicated. 
Zoster  is  the  most  severe  form  liable  to  be  met  with  in  the  gouty. 
The  pain  may  be  very  great,  especially  after  the  vesicles  dry  up. 
Boric  acid  or  zinc  ointment  on  lint,  firmly  bandaged  round  the 
chest,  affords  best  relief  at  first.  Quino-alkaline  mixture  may  be 
given  at  once,  and  the  subsequent  tormenting  neuralgia  is  best 
treated  by  quinine  in  full  doses,  and  by  arsenic. 

Change  of  air  and  walking  exercise  are  of  high  value  in  pro- 
moting recovery.  In  elderly  patients  the  suffering  may  be  very 
severe  and  prolonged,  even  for  months,  and  in  spite  of  all  forms 
of  treatment. 

7.— Treatment  of  Gouty  Cachexia  and  of  Gout  in 
Elderly  Persons. 

When  gouty  cachexia  is  established  in  any  case,  the  subject  of 
it  must  be  regarded  as  a  confirmed  invalid.  Such  patients  are 
sometimes  very  pitiable,  especially  if  severely  crippled.  Life  is 
burdensome,  and  each  day  brings  a  renewed  struggle  with  varie- 
ties of  incapacity  and  weariness.  The  conduct  of  each  case  natu- 
rally varies  according  to  its  precise  nature.  Degenerations  of 
tissues,  more  or  less  wide-spread,  are  the  prominent  features, 
and  the  symptoms  may  consequently  be  multiform  and  complex. 
There  is  commonly  advanced  renal  cirrhosis  with  associated  cardio- 
vascular change,  and  progressive  failure  of  cardiac  power  together 
with  renal  inadequacy.  There  may  be  grave  textural  decay  with 
little,  or  even  no,  tophaceous  deposit.  In  some  cases  the  latter 
predominates.  Bronchitis  is  common,  and  there  may  be  an  abid- 
ing eczema  in  parts,  usually  of  dry  character.  As  the  latter  hap- 
pens to  become  active  and  annoying,  relief  may  come  to  various 
symptoms  in  other  parts,  and  as  the  eczema  becomes  quiet,  other 
manifestations  may  be  aroused,  either  in  the  lungs  or  kidneys. 
Signs  of  vesical  irritation,  haemorrhage,  or  prostatic  gout  may 
supervene. 

The  mental  state  vaiues,  and  hence  there  may  be  great  depres- 
sion or  great  irritability,  peevishness,  or  querulousness. 

Such  patients,  if  crippled,  do  best  at  home,  and  should,  when 
possible,  live  on  one  floor.  Otherwise,  they  must  be  carried 
about.  If  the  strength  permits,  winter  should  be  passed  in  a 
sunny  and  sheltered  spot.  Warm  spots  on  the  Riviera  may  be 
resorted  to,  or  a  climate  such  as  that  of  Algeria  may  be  recom- 
mended. Not  many  patients,  however,  could  wisely  be  transported 
so  far  from  home.  Hastings,  Bournemouth,  and  Torquay  are 
amongst  the  best  English  winter  resorts  for  most  cases. 


414       TREATMENT    OF    THE    SEVERAL    VARIETIES    OF    GOUT. 

The  diet  must  vary  according  to  the  special  indications  of  each 
case,  and  be  regulated  mainly  with  reference  to  the  digestive 
capacity,  and  the  functional  activity  of  the  kidneys.  Milk,  fish, 
and  farinaceous  foods  suit  best,  but  sometimes  a  little  meat  is 
advisable  on  alternate  days.  Wine  is  not  proscribed,  as  a  rule, 
on  the  principle  that  the  patient,  and  not  his  disease,  is  to  be 
treated.  Two  to  four  ounces  of  mature  port  wine,  or  a  smaller 
quantity  of  whisky,  well  diluted,  may  be  taken  with  meals.  The 
general  nutrition  is  to  be  maintained  as  far  as  possible.  Any 
simple  mineral  water  may  be  taken.  Gentle  daily  exercise,  by 
walking,  or  in  a  carriage  or  wheeled  chair,  in  the  sun,  is  most 
desirable.  Failing  this,  or  in  addition  to  it,  friction  of  the 
body  should  be  practised  once  or  twice  daily,  so  as  not  to 
induce  subsequent  fatigue.  When  the  fingers  and  hands  are 
stiff,  a  small  piece  of  soft  wax  may  be  rolled  from  time  to 
time  in  the  hands,  to  promote  some  degree  of  flexibility  in  the 
parts.1      Net-making,  as  an  occasional  occupation,  is  also  useful. 

No  treatment  by  means  of  baths  or  mineral  waters  is  practi- 
cable or  advisable  for  the  subjects  of  gouty  cachexia.  The  time 
for  this  has  gone  by,  and  it  was  noted  by  Sydenham  that  no  good 
was  to  be  expected  from  such  methods. 

The  clothing  must  be  loose  and  warm,  and  woollen  materials 
be  used  for  all  parts  of  the  body. 

Exposure  to  chill  and  cold  winds  must  be  especially  avoided.  A 
fire  should  be  kept  up  all  night  in  the  bedroom  during  the  winter 
months,  and  the  rooms  be  kept  as  uniformly  as  may  be  at  a 
temperature  of  6o°  to  65°  F.  A  warm  pediluvium  at  bedtime 
is  very  soothing. 

Regular  action  of  the  bowels  is  important,  and  must  be  secured 
by  the  simplest  aperients  when  necessary.  No  strong  purging  is 
permissible. 

Sometimes  a  little  tonic  and  heematic  medicine  is  beneficial. 
Iron  may  be  given  in  small  doses,  as  the  syrup  of  the  iodide,  or  the 
ammonio-citrate  with  some  nux  vomica.  A  wineglassful  of  Spa 
or  Pyrmont  water  may  be  taken  after  a  principal  meal  once  in 
the  day.  Flatulency,  which  is  often  troublesome,  may  be  relieved 
by  spirit  of  cajuput  and  compound  tincture  of  lavender,  or  by  the 
spiritus  armoraciae  compositus.  In  old  people,  when  there  is  no 
renal  complication  but  much  pain  (and  they  commonly  bear  pain 
badly),  recourse  may  be  had  to  bromide  of  potassium  or  to  some 
mild  form  of  opiate  at  night.  Twenty  to  thirty  grains  of  any 
bromide  salt  may  be  given,  or  four  grains  of  compound  soap  pill 
1  Recommended  by  Aurelianus. 


PREVENTIVE    MEDICINAL    TREATMENT.  415 

with  rhubarb  or  colocynth  pill.      Paraldehyde  in  doses  of  thirty 
or  forty  minims  is  sometimes  very  serviceable.1 

Benzoate  of  lithium  with  nux  vomica  is  sometimes  useful 
during  the  day,  especially  for  any  vesical  uneasiness.  An  occa- 
sional mild  saline  aperient  in  the  morning  may  be  necessary 
every  tenth  or  fourteenth  day,  when  a  small  tumblerful  of  warmed 
Piillna  water  may  be  used. 

The  mind  must  be  withdrawn  from  gloomy  thoughts  and 
forebodings,  and  undue  introspection  must  be  discountenanced. 
Pleasant  reading,  and  the  society  of  cheerful  friends  avail  much  to 
reduce  ennui,  and  help  to  render  the  little  miseries  of  the  cachectic 
gouty  patient  less  unbearable. 

The  treatment  of  gout  in  elderly  persons  must  be  conducted 
on  very  different  principles  from  those  which  are  called  for  in 
younger  persons.  All  violent  and  vigorous  measures  are  bad. 
When  more  or  less  acute  articular  symptoms  supervene,  they  had 
better  not  be  too  much  regarded.  Colchicum  is  not  often  avail- 
able in  such  instances.  Eest  in  bed,  warm  applications,  and 
very  simple  alkaline  remedies  are  best.  Bromide  of  potassium 
is  a  very  suitable  drug,  and  may  be  given  several  times  in 
the  day. 

Eetrocedent  manifestations  may  be  treated  by  hot  pediluvia 
and  moderate  purgation,  and  stimulants  are  commonly  needed 
and  useful.  Opium  may  be  required  if  not  specially  contra- 
indicated.  The  great  points  to  be  observed  are  to  avoid  nimia 
diligentia  medici,  and  to  enforce  patience.  Special  complications 
may  be  gently  treated  as  they  arise. 

8.— Preventive  Medicinal  Treatment  of  Gout.  ' 

Such  measures  as  may  be  adopted  to  avert  recurrence  of  acute 
paroxysms  or  of  other  gouty  phases  may  be  appropriately  classed 
under  two  heads,  viz.,  (a.)  treatment  for  long  continuance  between 
the  attacks,  and  (b.)  that  for  preventing  an  impending  attack. 

In  the  former  case,  the  management  of  the  patient  is  best  con- 
ducted by  attention  to  the  habits,  diet,  and  mode  of  life  as  already 
discussed.  All  conditions  likely  to  depress  nervous  energy  are  to 
be  strenuously  avoided,  and  the  tone  of  the  entire  nervous  system 
must  be  maintained  in  every  possible  manner.  For  the  prevail- 
ing tendency  to  urichaemia,  the  most  rational  line  of  treatment  is 
careful   attention  to   the  dietary  in    accordance   with  the   prin- 

1  R  Paraldehyde  ttixl.,  Tinct.  Aurantii  Recentis  f5ss. ,  Syrupi  Simplicis  f5ss., 
Aquam  Destillatain  ad  fgi.     M.  ft.  Haustus.     Sig.     To  be  taken  at  bedtime. 


4 1 6   TREATMENT  OF  THE  SEVEEAL  VARIETIES  OF  GOUT. 

ciples  already  laid  down.  Medicinally,  alkaline  remedies  are  of 
the  highest  value;  but  inasmuch  as  these  cannot  always  be  taken, 
and  constant  dosing  with  physic  is  objectionable,  I  believe  the 
best  plan  to  be  that  of  maintaining  the  due  alkalinity  of  the 
blood  by  some  potable  mineral  water,  taken  for  ten  or  fourteen 
days- in  each  month.  Of  these,  the  most  powerful  and  suitable, 
I  think,  is  Vichy  water,  taken  to  the  extent  of  a  pint  in  the 
day  at  and  between  meals.  The  Celestins  spring  furnishes  the 
most  appropriate  combination.  Potass  and  lithia  waters  may  be 
used  for  the  same  purpose,  also  Giesshubel,  Kroninquelle,  Oon- 
trexeville,  and  Bath  waters.  These,  with  the  Nassau  Selters  and 
any  of  the  Rhine  waters  of  the  Apollinaris  district  are  suitable 
at  other  times.  In  this  country,  Buxton  and  Harrogate  may  be 
resorted  to  in  summer,  and  Bath  in  winter. 

For  more  direct  medication,  and  for  dyspeptic  fits,  which  are 
often  premonitory  of  paroxysms,  there  is  no  better  treatment  than 
that  by  drachm  doses  of  the  pulvis  rhei  compositus  taken  in 
peppermint  water,  with  forty  minims  of  aromatic  spirit  of  ammo- 
nium, at  bedtime.  The  tinctura  rhei  in  half-ounce  doses,  with 
fifteen  grains  of  bicarbonate  of  potassium  in  an  ounce  of  chloroform 
water,  may  be  taken  with  advantage  an  hour  before  dinner. 

Patients  sometimes  dose  themselves  with  strong  aperients  in 
order  to  avert  impending  paroxysms,  and  compound  colocynth 
pill  with  colchicum  and  quinine  is  in  some  repute  for  this  purpose. 

Some  practitioners  combine  calomel  with  acetous  extract  of  col- 
chicum and  morphine  in  a  pill  to  be  taken  over-night,  and  followed 
up  next  morning  with  some  simple  aperient.  This  plan  is  some- 
times advisable,  and  may  suit  such  patients  as  are  still  vigorous, 
and  unharmed  by  gouty  dyscrasia.  There  are  two  cautions  to  be 
noted  respecting  treatment  of  this  kind.  One  is,  that  strong 
aperients  may  tend  to  precipitate  the  evil  combated,  and  aggra- 
vate a  slight  into  a  severe  gouty  paroxysm.  The  other  is,  that 
patients  relying  on  the  efficacy  of  this  smart  medication  are  apt 
to  be  very  imprudent  in  their  diet  and  manner  of  life,  and  so  fail 
to  restrain  their  appetites,  trusting  to  the  remedy  to  ward  off  the 
evil  effects  of  their  vicious  indulgence.  Treatment  of  the  kind 
indicated  may  prove  a  rude  interruption  to  the  general  equability 
of  functions  which  is  essential  for  the  comfort  of  the  gouty,  and 
is  often  better  replaced  by  the  milder  measures  referred  to,  even 
if  they  be  repeated  over  several  nights.  In  either  case,  the  patient 
is  not  to  consider  the  medicinal  dosage  a  warrant  for  continued 
indulgences,  but  is  to  combine  with  this,  as  an  essential  part  of  the 
treatment,  a  careful  regulation  of  his  life  and  dietary. 


TREATMENT  OF  BLENDED  GOUT  AND  STRUMA.    417 

A  remedy  of  considerable  power  in  warding  off  attacks  of  gout  is 
castor  oil,  taken  in  doses  of  one  or  two  drachms  early  in  the  morn- 
ing for  two  or  three  days.  "Where  hepatic  fulness  prevails,  with 
plethora  of  the  portal  venous  system,  and  especially  in  the  olive- 
complexioned  arthritic  habit  of  body,  this  drug  is  sometimes  of 
great  use. 

Hepatic  stimulants,  such  as  euonymin  in  gr.ss.  to  gr.ij.  doses, 
also  act  well  in  these  cases,  generally  better  with  as  much  calomel 
taken  over-night,  and  followed  by  four  ounces  of  Piillua  water  in 
the  morning. 

Two  doses  of  the  following  medicine  taken  during  the  day  are 
of  use  in  many  cases  : — 

B  Quininse  Sulphatis,  gr.ij.,  Acidi  Sulphurici  Diluti,  vr[iss.,  Potassii  Iodidi, 
gr.iij.,  Tinct.  Colchici,  in.sij.,  Decoctum  Sarsas  Comp.  ad  fgi.  M.  ut  fiat  Haustus. 
Sig.     To  be  taken  in  a  wineglassful  of  water  between  meals. 

Quinine  in  a  dose  of  ten  grains  has  been  known  to  cut  short 
a  paroxysm,  but  this  practice  cannot  be  commended. 

An  alkaline  aperient  such  as  the  following  proves  useful,  and 
is  best  taken  early  in  the  morning : — 

B  Sodii  et  Potassii  Tartratis,  5i->  Sodii  Bicarbonatis,  gr.xx.,  Decocti  Aloes 
Cornp.  fgi.     M.  ft.  Haustus. 

Colchicum  in  small  doses  may  be  added  to  any  medicine  given 
after  gouty  attacks,  and  when  any  gouty  phases  are  present.  No 
ill  effects,  so  far  as  my  experience  goes,  are  likely  to  ensue  from 
its  use,  even  if  continued  for  weeks  at  a  time. 

Treatment  of  Blended  Gout  and  Struma. 

Treatment  for  blended  diathetic  states  will  vary  according  as 
one  or  the  other  is  more  urgent  for  the  time  being. 

Where  gout  and  struma  co-exist,  the  constitution  is  natu- 
rally frail,  and  a  supporting  line  of  treatment  is  called  for. 
Strumous  ailments  are  naturally  more  prominent  in  early  life, 
but  may  crop  up  in  later  years  in  the  form  of  senile  scrofula. 
Advanced  age  may  be  reached  with  this  untoward  combination. 
Such  patients  may  do  well,  if  happily  circumstanced  as  to  means 
and  calling  in  life.  They  are  more  than  others  vulnerable  and 
liable  to  break  down  under  excess  or  riotous  living.  Country 
and  open-air  life  is  desirable,  and  sedentary  occupations  should 
be  shunned.  A  career  in  a  healthy  part  of  India  or  on  the 
Prairies  may  avert  many  varieties  of  ailment,  and  set  up  the 
constitution  for  the  remainder  of  life.      Boys  thus  affected  should 

2  D 


4 1 8      TREATMENT   OF    THE    SEVERAL   VARIETIES    OF   GOUT. 

be  sent  from  homes  in  town  to  good  schools  in  the  country,  and 
be  forced  into  all  the  wholesome  activities  of  English  school-life. 
Girls  do  best  at  home,  carefully  avoiding  Continental  schools, 
even  under  the  best  auspices,  and  should  lead  open-air  lives  with 
plenty  of  active  exercise,  and  not  too  much  study,  to  which  their 
quick  wits  may  sometimes  urge  them.  Chlorosis  may  occur  in 
these  subjects,  also  obesity,  and  iron  may  be  badly  borne.  It  is 
better  replaced  by  quinine  and  aperients  containing  magnesium 
salts,  and  by  those  containing  aloes.  Sea-air  favours  repression 
of  the  strumous  element,  but  may,  unhappily,  prove  harmful  for 
the  gouty  proclivity.  High  and  dry  situations  suit  best,  with  a 
short  seaside  residence  each  year,  when  sea-bathing  may  be  had. 

Good  diet  and  wine  are  generally  necessary  with  advancing 
years,  and  no  very  vigorous  medicinal  treatment  for  any  acute 
gouty  outburst  is  desirable.  The  waters  of  Harrogate  and  Wood- 
hall  Spa  are  especially  indicated  in  these  cases,  the  good  in- 
fluence of  sulphur,  barium,  calcium,  and  iodine  salts  being  in 
repute. 

Treatment  of  Blended  Gout  and  Syphilis. 

Syphilis,  if  treated  from  the  first  infection  secundum  artem, 
should  after  two  years  give  little  (if  any)  subsequent  trouble  in 
any  case.  Owing  to  many  circumstances,  inefficient  and  in- 
sufficient treatment  is,  unhappily,  undergone  in  many  cases,  and, 
hence,  later  phases  of  lues  come  to  exert  a  malign  influence  in 
the  system  for  many  years.  Gouty  dyscrasia  exercises  a  modifying 
action  on  these  manifestations,  and  venereal  taint,  in  its  turn, 
comes  to  modify  the  varied  expressions  of  gout.  The  treatment 
must  vary  according  to  the  nature  of  the  earlier  management  of 
the  syphilitic  infection,  and  the  constitution  of  the  patient. 
Note  must  be  taken,  too,  of  the  possibility  of  unconscious  infec- 
tion, especially  where  secondary  symptoms  have  been  little  marked, 
unobserved,  or  unheeded. 

If  the  patient  be  robust,  and  has  had  imperfect  mercurialization, 
a  mercurial  course  should  be  carried  out  with  prudence,  and 
followed  up  by  iodides,  alkalies,  and  sarsaparilla  in  full  doses  with 
tonics.  A  "  washing  out "  hydropathic  course  is  of  much  value 
in  these  cases,  and  may  be  carried  out  at  Harrogate,  Strathpeffer, 
Aix-la-Chapelle,  or  at  Aix-les-Bains.  Careful  management  is 
required  for  at  least  two  years,  and  good  results  are  hardly  to  be 
looked  for  in  less  time. 

Nourishing  but  unstimulating  dietary  is  called  for.  The 
skin-affections  may  be  amongst  the  most  troublesome  to  treat. 


TREATMENT    OF   BLENDED    GOUT    AND    SYPHILIS.         419 

Alkalies  with  arsenic  or  Donovan's  solution  are  very  useful, 
and  mercurial  lotions  may  be  required  in  the  local  treatment  of 
obstinately  recurring  patches  on  the  integument,  or  on  the  tongue 
and  fauces.  Arthritic  swellings  and  tertiary  changes  in  bones 
call  for  iodides  and  hot  douching,  and  a  course  of  sarsaparilla 
taken  as  a  diet-drink  is  of  high  value.  Not  less  than  a  pint  of 
the  compound  decoction  should  be  given  daily  for  weeks  together. 
A  very  regular  and  wholesome  life  should  be  led,  and  all 
excesses  avoided.  With  temporary  decline  of  health,  there  is 
apt  to  be  recurrence  of  both  syphilitic  and  gouty  manifestations, 
and,  hence,  worry  and  overwork  are  to  be  guarded  against. 


CHAPTER  XXII. 

ON  THE  SUITABILITY  OP  ALCOHOLIC  AND  OTHER 
DRINKS,  WITH  GENERAL  REMARKS  ON  THE 
DIETARY   PROPER   FOR   THE    GOUTY. 

I  have  already  discussed  the  dietary  proper  for  cases  of  acute 
gout,  and  that  suitable  for  the  intervals  between  the  paroxysms. 
It  now  remains  to  add  some  special  advice  respecting  alcoholic 
and  other  diet-drinks  for  those  goutily  disposed,  and  I  shall  also 
discuss  here  in  more  detail  the  employment  of  certain  other  articles 
of  food  by  such  patients. 

One  of  the  most  important  points  in  treating  cases  of  gout 
relates  to  the  diet  in  respect  of  fluids,  and  more  especially  to  the 
particular  alcoholic  fluids  that  are  permissible.  On  this  subject 
the  greatest  variety  of  opinions  prevails  both  in  and  out  of  the 
profession.  It  would  be  of  interest  to  draw  up  a  list  of  these 
opinions,  and  it  would  then  not  improbably  be  found  that  every 
known  drinkable  fluid,  alcoholic  or  otherwise,  had  been  found 
suitable  in  particular  cases.  The  profession  is  often  twitted  with 
inconsistency  and  changes  of  opinion  on  this  matter,  and  it  must 
be  conceded  that  such  charges  are  not  always  unfairly  made.  For 
a  long  time  it  was  held  that  port  wine  was  especially  to  blame  for 
inducing  goutiness  ;  that  the  stronger  wines,  such  as  Madeira,  Bur- 
gundy, and  sherry,  were  all  gout-producing.  Beer  is  notoi'iously 
held  in  disfavour,  together  with  all  varieties  of  malt  liquors.  Cider 
has  been  held  to  be  innocuous.  The  sparkling  and  incompletely 
fermented  wines,  of  which  champagne  in  its  many  varieties  and 
qualities  is  the  type,  are  likewise  commonly  held  in  disrepute  for 
the  gouty.  On  the  other  hand,  if  we  were  to  believe  what  we 
often  hear  alleged  by  the  goutily  disposed  amongst  the  laity,  we 
should  hold  nearly  all  these  liquors  to  be  innocent,  and  even 
wholesome  for  such  sufferers.  Thus  I  meet  with  patients  who 
stoutly  affirm  that  they  hold  their  gout  at  bay  by  taking  port 


SUITABILITY    OF   ALCOHOLIC    AND    OTHER    DRINKS.       42 1 

wine  regularly,  and  have  never  been  troubled  since  they  found 
benefit  in  this  fashion.  And  the  same  with  respect  to  cham- 
pagne and  cider.  There  is  a  practical  unanimity  regarding  malt 
liquors  as  being  unsuitable  and  gout-provoking,  yet  one  meets 
with  gouty  patients  who  can  take  daily  with  impunity  a  little 
mild  ale. 

My  experience  has  taught  me  that  this  impunity  is  not  always 
so  complete  in  the  long-run  as  is  asserted,  and  further,  that  it  is 
in  most  cases  quite  impossible  to  lay  down  rules  for  patients  of 
whose  life-histories  and  special  capacities  one  is  practically  igno- 
rant. 

Taking  the  statements  of  gouty  patients  as  usually  made  by 
themselves  in  these  respects,  what  is  the  practical  outcome  of  their 
evidence  ?  We  should  ask  this  question  with  an  open  mind,  and 
weigh  the  evidence  dispassionately ;  and  a  similar  question  relates 
equally  to  the  digestive  capacity  for  the  various  articles  of  solid 
food  taken  by  the  gouty. 

My  experience  leads  me  to  affirm  confidently  that  each  man, 
and  in  particular  each  gouty  man,  is  practically  a  law  to  himself; 
and  that  the  patient,  if  he  be  honest  with  himself,  and  not  a 
grossly  sensual  person,  can  often  better  prescribe  for  himself,  in 
respect  of  the  fluids  he  can  best  digest,  than  any  physician.  For 
those  who  have  only  begun  to  manifest  gout,  there  are  general 
rules  of  obvious  importance ;  but  for  those  who  have  the  expe- 
rience of  several  or  many  attacks,  it  will  commonly  be  found  that 
they  well-know  what  may  be  taken  with  impunity,  and  what  is 
fairly  certain  to  be  harmful.  Such  an  experience  does  not  by 
any  means  always  bring  wisdom  or  the  control  necessary  to  forego 
the  harmful  agent.  Were  this  so,  our  task  would  be  greatly 
lightened.  It  happens,  unfortunately,  that  amongst  the  charac- 
teristics of  the  gouty  is  often  a  keen  and  fine  sense  of  percep- 
tion of  the  best  and  most  subtle  agents  that  minister  to  the 
palate,  and  with  this  is  commonly  found  a  disposition  to  yield  to 
these  gratifications,  and  to  various  other  indulgences,  and  an 
equally  strong  indisposition  to  control  such  appetites. 

It  is  certain  that  some  gouty  persons  can  take  strong  liquors 
with  impunity,  provided  the  quantity  be  small,  and  they  do  not 
mix  several  varieties  at  one  meal,  or  take  several  in  any  one  day. 
Few  can  for  any  long  time  take  champagne,  even  of  the  best 
sorts,  regularly.  Many  can  take  port  wine  daily,  while  others 
are  at  once  rendered  acutely  gouty  by  a  single  glass  of  either  of 
these  wines.  There  is  fairly  unanimous  agreement  as  to  the 
gout-provoking  qualities  of  Burgundy,  and  few  can  take  even  a 


42  2  DRINKS    AND    DIETARY. 

little  of  this  for  many  days  with  impunity.  Bordeaux  wine,  when 
mature,  is  much  better  borne  by  the  majority  of  gouty  subjects, 
but  the  base  compounds  which  pass  for  the  products  of  the  Bor- 
deaux districts  under  the  name  of  "  claret,"  and  which  are  either 
factitious,  or  the  mixed  products  of  Spain,  Portugal,  Algeria,  or 
Australia,  having  nothing  in  common  with  the  real  article  beyond 
the  colour,  are  commonly  very  noxious.  White  Burgundy  and 
white  Bordeaux  wines  are  ill-suited  to  the  gouty,1  unless  well- 
diluted  and  taken  in  strict  moderation,  not  exceeding  half  a  pint 
in  the  day.  Rhenish  wines  are  also  acid  and  harmful ;  those  of 
the  Moselle  districts  are,  however,  less  acid,  and  rather  better 
borne.  Australian,  Californian,  Hungarian,  Italian,  Greek  and 
other  Mediterranean  wines  are  too  strong,  and  after  a  time 
generally  disagree.  Exceptions  are,  however,  met  with,  some 
gouty  persons  being  able  to  take  some  Hungarian  wines  in 
moderation. 

In  the  case  of  all  wines,  it  is  probably  true  that  much  depends 
on  the  quality,  and  everything  on  the  quantity.  Wines  that 
have  been  long  matured  in  the  bottle  are  least  harmful,  and,  as 
has  been  pointed  out  by  Dr.  Burney  Yeo,  those  which  favour 
diuresis  are  also  least  likely  to  do  mischief.  In  warm  weather, 
with  a  freely-acting  skin,  diluted  wine  is  less  likely  to  be  harmful. 
Strong  and  sweet  wines  are  most  certain  to  disagree.  The  fact 
that  many  gouty  men  can  drink  with  seeming  impunity,  and 
with  alleged  benefit,  wine  that  is  proverbially  known  to  be 
gout-inducing,  can  only  be  explained  on  the  ground  that  such 
wine  is  really  suitable  for  them  as  individuals ;  and  it  will  gene- 
rally be  found  that  no  other  wines  are  taken  by  them.  Hence 
the  apparent  paradox  that,  for  some  gouty  persons,  port  wine  is 
not  gout-inducing,  and  that  even  champagne  can  be  long  taken 
with  impunity  ;  while,  for  others,  a  single  glass  of  either  is  sooner 
or  later  provocative  of  more  or  less  goutiness.  Each  individual 
is  therefore  a  law  to  himself,  and  it  is  certain  that  no  hard  and 
fast  rules  can  be  universally  appropriate.  In  practice  this  is 
certainly  found  to  be  the  case.  Disregard  of  these  facts  has  led 
to  certain  wines  being,  as  it  were,  from  time  to  time  in  fashion 
amongst  the  gouty,  the  doctors  being  said  now  to  recommend  this, 
and  now  that — all  of  which  is  very  unworthy  of  the  profession, 
since  fashions,  either  in  physic  or  dietetics,  may  be  safely  pro- 

1  Lecorche*  is  of  a  different  opinion,  and  recommends  white  wines  for  gouty 
persons.  They  contain  little  tannin,  a  good  deal  of  potash,  and  act  as  diuretics. 
Red  wines  he  is  less  in  favour  of,  as  containing  more  tannin,  which  he  affirms  to 
cause  increased  formation  (retention)  of  uric  acid. 


CIDER.  423 

nounced  wrong.  The  capacity  of  the  gouty  for  alcoholics  of  all 
sorts  varies  not  only  in  respect  of  the  quality,  but  very  much  also 
in  respect  of  the  amount  taken ;  thus,  some  can  only  take  a  little 
wine  occasionally  with  impunity,  and  must  not  indulge  in  that 
for  many  consecutive  days.  This  capacity  varies  infinitely,  too, 
accordingly  as  the  individual  has  acquired  what  may  be  called  an 
alcoholic  habit,  and  also  whether  he  leads  an  active  life  in  fresh 
air,  or  is  confined  indoors,  in  sedentary  pursuits,  and  in  the 
exhausted  air  of  large  towns. 

In  any  case,  it  is  certain  that  the  alcoholic  habit  can  only  be 
gratified  so  far  as  is  compatible  with  the  patient's  honest  ex- 
perience of  his  best  digestive  state  and  general  health.  If  diges- 
tion be  impaired  or  the  general  health  lowered,  the  gouty  patient 
is  rendered  a  prey  to  renewed  attacks,  or  to  various  phases  of 
discomfort  and  goutiness. 

Cider  is  sometimes  taken  with  impunity  by  goutily  disposed 
persons,  but  it  is  apt  to  disagree  with  most  of  them  after  a  short 
time,  even  when  it  is  sound  and  in  good  condition.  Unlike  beer, 
cider  is  not  a  diuretic.  It  can  seldom  be  long  borne  by  those 
leading  town-lives.  My  friend,  Mr.  Richard  Davy,  of  the  West- 
minster Hospital,  has  kindly  noted  his  experiences  of  the  employ- 
ment of  cider  in  North  Devon  in  relation  to  gout-inducing 
qualities,  as  follows  : — 

"  I  cannot  recall  nor  ascertain  any  single  case  of  gout  happening  to  a  farm- 
labourer  who  has  made  cider  his  staple  drink,  but  can  mention  cases,  more  than 
one,  of  gout  complicated  with  rheumatism  where  men  have  been  free  drinkers  of 
cider  associated  with  gin,  beer,  or  alcohol  in  mixed  form. 

"  Thirty- seven  years  ago  I  recall  my  grandfather  and  all  the  resident  yeomen  in 
the  Bow  district,  who  were  well-to-do  and  passed  easy  lives,  being  the  subjects 
of  true  gout  (evidenced  by  the  passing  of  chalk-stones),  but  not  one  instance  of 
any  of  their  servants  or  farm-labourers  suffering  similarly.  Their  distress  was 
crippling  rheumatism,  due  to  exposure  and  hard  work. 

"  Cider  is  popularly  deemed  by  them  to  be  a  very  wholesome  beverage ;  to 
grant  an  immunity  from  stone  in  the  bladder  ;  not  to  provoke  gout,  but,  as  they 
say,  '  if  they  have  the  gout  in  them,  eider  might  feed  it.'  Cider  is  acid,  and  turns 
blue  litmus  paper  red.  The  drinking  of  three  quarts  per  diem  does  not  affect 
their  loins  nor  big-toe.  In  this  harvest  (1888)  a  consumption  of  ten  quarts  per 
diem  per  man  has  not  been  an  unusual  quantity.  The  supply  of  cider  in  the 
harvest-field  is  practically  unlimited. 

"  Good  living,  free  and  mixed  drinking,  and  furthermore,  no  work  with  absence 
of  mental  anxiety,  are  generally  (by  the  Devonshire  people)  supposed  to  be  the 
prime  factors  in  the  production  of  gout. 

"  The  use  of  cider  in  Devon  is  mostly  associated  with  hard  labour  and  free 
transudation.  It  is  not  drunk  (as  a  rule)  in  large  quantities  in  the  public-houses. 
Should  drunkenness  ensue,  the  resultant  headache  is  prolonged  and  insufferable." 

These  observations  relate  to  "  rough  "  or  fully  fermented  cider. 
Sweet  or  imperfectly  fermented  cider  is  certainly  provocative  of 


424  DRINKS    AND    DIETARY. 

gout ;  the  same  rule,  therefore,  holds  good  with  respect  to  this 
beverage  as  obtains  in  the  case  of  wines.  The  amount  of  alcohol 
in  cider  is  under  five  per  cent. 

The  drink  so  commonly  taken  by  the  lower  classes  in  London, 
known  as  "  four  ale,"  is  exceedingly  gout-provoking.  It  is  acid, 
and  not  always  free  from  some  degree  of  lead-impregnation, 
especially  the  portion  that  has  lain  over-night  in  contact  with 
pewter  pipes,  and  which  is  sold  at  a  low  rate  to  topers. 

The  fact  that  many  persons  find  themselves  compelled  to 
abstain  from  all  strong  drinks  because  they  cannot  drink  them 
with  impunity  and  comfort,  is  probably  in  itself  significant  of 
gouty  proclivity.  In  respect  of  any  alcoholic  drink,  it  may  be 
affirmed  that,  for  those  goutily  disposed,  it  is  often  possible  to 
take  a  certain  quantity  regularly  with  impunity.  Any  deviation 
from  the  daily  habit,  either  as  to  quantity  or  as  to  the  particular 
wine  taken,  may  at  once  induce  indications  of  goutiness. 

In  this  case,  as  in  others  relating  to  the  routine  and  nutritive 
rhythm  of  daily  life,  the  importance  of  equilibration  and  an  even 
tenour  of  habit  is  well  seen. 

Though  the  fact  does  not  admit  of  full  explanation,  it  is  practi- 
cally certain  that  the  gout-provoking  qualities  of  alcoholic  liquids 
are  in  relation  to  the  more  or  less  completeness  of  the  fermentation 
they  have  undergone.  It  is  proved  that  gout  does  not  exist  or 
tend  to  develop  amongst  spirit-drinking  populations ;  that  it  is 
somewhat  prevalent  where  wines  are  largely  used,  and  most 
established  where  incompletely  fermented  wines  and  malt  liquors 
are  freely  partaken  of.  Thus,  porter,  ale,  champagne,  Madeira, 
sherry,  canary,  Australian,  Italian,  Greek,  and  Californian  wines 
are  all  gout-producing  liquors.  Good  Bordeaux  wine  is  the  best 
natural  wine,  because  most  completely  fermented,  and  is  of  all  such 
liquors  the  least  harmful  for  the  gouty.  The  wines  of  the  Moselle 
and  the  Rhine  come  next  in  order,  but  some  of  the  highest  classes 
amongst  these  are  powerful  and  very  acid.  These  are  admitted  to 
the  Carlsbad  dietary,  and  often,  I  think,  with  bad  results.  Those 
wines  in  which  fermentation  is  checked  and  sugar  added  are  the 
most  gout-provoking  of  all.  The  lighter  beers  of  Germany,  Aus- 
tria, and  Scandinavia  appear  to  be  harmless  for  the  gouty,  unless 
taken  immoderately.  Residents  in  towns,  goutily  disposed,  leading 
sedentary  lives,  are  seldom  long  tolerant  even  of  light  Lager 
beer. 

The  expense  necessary  to  procure  trustworthy  wine  is  a  great 
drawback  to  the  use  of  even  the  little  that  is  suitable  for  the 
gouty,  and  hence  in  recent  years  there  has  been  recourse  to  purer 


VARIOUS    WINES.  425 

alcohols  in  the  forms  of  brandy  and  whisky.  The  latter  is  well- 
borne  by  the  gouty,  especially  if  it  be  old  and  mature,  diluted  and 
taken  with  one  meal  in  the  day,  presumably  at  dinner. 

It  is  clear  from  the  foregoing  remarks  that,  as  a  general  rule, 
all  alcoholics  must  be  regarded  as  entailing  a  measure  of  risk  for 
the  gouty,  and  Sir  Thomas  Watson's  excellent  advice  to  any  young 
person  showing  signs  of  the  disease  may  well  be  enforced.  It 
was  to  the  effect  that  it  was  well  worth  any  such  person's  while 
to  give  up  the  use  of  all  alcoholics,  and  become  a  water-drinker.1 

It  is  well-established,  however,  that  total  abstainers  are  by  no 
means  exempt  from  gout  in  many  of  its  manifestations  ;  and  in 
the  case  of  certain  persons  who  show  signs  of  gout  for  the  first 
time  in  middle  or  late  life,  it  is,  in  my  experience,  not  a  wise 
practice  to  enforce  complete  abstinence  from  all  forms  of  alcohol. 
For  younger  persons  the  case  is  often  very  different,  but  no  hard 
and  fast  rule  can  be  laid  down.  I  feel  sure  that  Sydenham  was 
right  in  condemning  water-drinking  for  the  gouty.  "  Water 
alone  is  bad  and  dangerous,  as  I  know  from  personal  experience. 
When  taken  as  the  regular  drink  from  youth  upwards,  it  is  bene- 
ficial." Herein  lies  a  great  clinical  fact  which  needs  to  be  duly 
considered,  especially  at  the  present  time. 

The  gout-provoking  qualities  of  alcoholic  liquids  vary  in  a 
remarkable  manner  in  different  individuals.  I  have  collected 
from  various  sources  many  noteworthy  examples  in  proof  of 
this.  Thus,  Marchal  (de  Calvi)  records  a  case  of  a  man,  son 
of  a  gouty  man,  who  had  gravel,  in  whom  a  little  rum  invari- 
ably caused  pain  in  the  right  great  toe-joint.  No  other  liquor 
acted  similarly.  I  have  notes  of  a  gouty  man  in  whom  whisky 
caused  pains  in  the  joints,  and  of  another  in  whom  Burgundy 
and  champagne  taken  at  dinner  were  sure  to  bring  out  gout  on 
the  following  day.  Another  man,  if  he  took  any  white  wine,  was 
sure  to  be  awaked  in  the  night  suffering  from  severe  cramps  in 
the  legs.  Champagne,  especially  if  of  inferior  quality,  will  fre- 
quently induce  this  symptom,  and  cause  pain  in  the  small  joints 
of  the  hands  and  feet,  as  well  as  burning  sensation  (causalgia)  in 
the  soles. 

In  another  case,  any  wine  will,  within  twelve  hours,  cause  pain 
in  the  right  metacarpo-phalangeal  joint,  and  set  up  headache  next 
day.  A  few  glasses  of  port  wine  or  Madeira  will  often  induce 
gouty  pains  in  various  joints  within  a  few  hours,  and  the  same 

1  "  With  an  absence  of  alcohol  in  any  shape,  coupled  with  an  absence  of  hereditary 
predisposition  derived  from  alcohol-drinking  ancestors,  gout  would,  practically,  be 
unknown." — Garrod,  Lumhian  Lectures,  1S83.     Lancet,  April  7,  p.  582. 


426  DRINKS    AND    DIETARY. 

result  has  followed  within  an  hour  in  other  cases.  The  adage 
that  "  a  man,  after  the  age  of  forty,  is  either  a  fool  or  his  own 
physician,"  is  especially  true  in  respect  to  alcoholic  habits  for  the 
gouty. 

In  my  experience,  it  is  very  unwise  for  a  man  to  make  any 
profound  change  in  his  habits  of  life  after  the  age  j  ust  mentioned  ; 
hence,  I  cannot  countenance,  as  a  rule,  any  change  from  moderate 
wine-drinking  or  meat-eating  to  habits  of  water-drinking  and,  so- 
called,  vegetarianism.  These  alterations  are  surely  wrong,  and  it 
is  within  my  knowledge  that  they  are  sometimes  distinctly  harm- 
ful. If  such  deviations  from  civilized  life — which,  be  it  remem- 
bered, is  seldom,  if  ever,  a  theoretically  natural  life — are  thought 
proper,  they  had  better  be  begun  in  early  youth,  in  which  case 
the  results  are  likely  to  be  very  different. 

I  have,  exceptionally,  met  with  a  few  gouty  persons  who  have 
found  better  health  after  abstention  from  butcher's  meat  and  all 
alcoholics,  but  it  will  seldom  be  found  practicable,  or  even  desir- 
able, to  prescribe  such  a  regimen. 

The  influence  of  heredity  upon  the  acquirement  of  habits  by 
individuals  has  not  been  much  considered,  but  it  must  be  certain 
and  potential.  In  the  practice  of  physic  this  factor  has  to  be 
reckoned  with,  and  it  can  hardly  be  right,  as  a  matter  of  routine, 
to  interfere  rudely  with  acquired  dietetic  habits  and  tastes  which 
properly  represent  the  requirements  of  the  individual  in  respect 
of  his  trophic  equilibrium. 

The  average  amount  of  alcohol  in  spirits  varies  from  thirty-five 
to  forty-four  per  cent.  Port  wine  contains  nineteen,  Madeira 
eighteen,  sherry  seventeen,  champagne  eleven,  Burgundy  ten, 
Bordeaux  and  Rhine  wines  eight  per  cent.  Porter  contains  over 
six,  ale  three  to  six,  and  cider  four  per  cent,  of  alcohol. 

Wines  are  more  acid  than  malt  liquors,  and  spirits  contain 
least  acid.  Malt  liquors  are  less  acid  than  wines,  but  as  much 
greater  quantity  of  them  is  taken,  they  are  virtually  as  acid  as 
wines  for  general  consumption.  A  pint  commonly  contains 
twenty-five  grains  of  free  acid. 

The  most  saccharine  wines  are  Tokay,  malmsey,  port,  cham- 
pagne, Madeira,  and  sherry.  Burgundy,  Bordeaux,  Rhine,  and 
Moselle  wines  are  void  of  sugar.  Porter,  ale,  and  cider  all  con- 
tain sugar,  sometimes  as  much  as  an  ounce  in  a  pint. 

The  gout-provoking  qualities  of  alcoholic  drinks  mainly  depend 
on  the  amount  of  acid  and  sugar  contained  in  them.  The  com- 
bination of  these  two  principles  gives  any  one  of  them  its  special 
noxious  qualities. 


SUGAR.       FRUITS.  427 

Sugar. — For  some  years  past  it  has  been  a  common  practice 
to  forbid  the  use  of  sugar,  or  to  limit  it  very  much,  in  the  case 
of  gouty  persons. 

It  is  certain  that  gout  is  not  prevalent  amongst  the  largest 
consumers  of  sugar,  and  the  production  and  use  of  this  food 
extend  annually  all  over  the  world. 

It  is  not  proved  that  sugar  by  itself  is  harmful  to  the  gouty  ; 
but  there  is  evidence  to  show  that  if  it  be  freely  taken  in  addition 
to  a  varied  and  mixed  diet,  especially  with  certain  articles  and  with 
wine,  an  imperfect  fermentative  process  is  set  up  in  the  stomach  and 
small  intestines,  which  tends  to  provoke  flatulency  and  acidity. 
It  is,  therefore,  in  this  manner  that  sugar  proves  harmful  to  those 
disposed  to  gout.  The  products  of  the  digestion  of  almost  all 
fruits,  with  or  without  sugar,  appear  to  be  particularly  noxious  to 
such  persons,  and  thus  all  the  varieties  of  jams,  tarts,  and  so- 
called  sweet  courses,  are  found  to  be  improper  for  gouty  patients. 
The  capacity  for  digestion  of  these,  as  of  various  fruits,  is  found 
to  vary  much  in  different  gouty  individuals.  Some  can  take  fruit, 
raw  or  cooked,  without  sugar  with  impunity,  but  few  can  con- 
tinue to  take  both.  Fruit  by  itself  may  be  borne  in  small 
quantity  early  in  the  day,  and  apart  from  meals,  by  some  gouty 
persons,  who  would  suffer  if  the  same  were  taken  after  an  ordi- 
nary meal,  and  especially  if  rich  dishes  or  wine  formed  part  of 
that  repast. 

The  capacity  to  digest  different  fruits  varies  also  in  healthy 
individuals.  Thus,  some  persons  can  take  strawberries,  rasp- 
berries, apples,  pears,  and  bananas  with  impunity ;  others  digest 
some  of  these  with  difficulty,  and  are  certainly  rendered  gouty 
by  them.  Taken  with  sugar,  fermentative  change  is  very  apt  to 
arise,  and,  hence,  fruits  are  often  rightly  proscribed  together  with 
sugar  in  the  dietary  of  the  gouty.  It  is.  certainly  safer  for  such 
patients  to  avoid  fruits  altogether.1  The  vegetable  acids  consti- 
tute the  noxious  principle  contained  in  them.2 

Sugar,  together  with  plain  food,  and  in  moderation,  is  scarcely 
to  be  reckoned  harmful,  but  the  idiosyncrasies  of  each  gouty 
individual  must  be  taken  into  account.  Patients  tell  of  relief 
from  pains  and  uncomfortable  symptoms  after  giving  up  sugar, 
and,  hence,  it  may  be  assumed,  as  in  the  case  of  malt  liquors, 
that   such    food   is   unsuitable   for  them,  and   they  are  wise   to 

1  Linnaeus  is  affirmed  to  have  been  cured  of  gout  by  eating  strawberries.  I  am 
not  prepared  to  lend  credence  to  this.  Crude  cherries  have  been  known  to  induce 
a  gouty  paroxysm. 

2  Sir  Andrew  Clark  informs  me  that  he  absolutely  forbids  all  fruits  to  gouty 
persons. 


428  DRINKS    AND    DIETARY. 

abstain.  In  such  cases  satisfaction  is  sometimes  gained  by  the 
substitution  of  saccharine,  a  flavouring  matter,  be  it  observed, 
and  not  a  food,  albeit  practically  harmless.  Glycerine  may  be 
similarly  employed,  but  is  less  palatable  for  continuance. 

The  sweeter  fruits,  peaches  and  grapes,  are  often  ill-borne  by 
the  gouty,  especially  if  taken  with  other  food.  Melon  in  modera- 
tion, at  the  beginning  of  a  meal,  is  probably  little  harmful  in  any 
case.  All  candied  and  preserved  fruits,  such  as  citron,  oranges, 
and  preserved  ginger,  are  very  bad  for  the  gouty. 

That  no  untoward  fermentative  change  results  during  digestion 
of  saccharine  and  alcoholic  matters  is  proved  by  the  general  harm- 
lessness  for  the  gouty  of  liqueurs,  and  of,  so-called,  toddy  in  strict 
moderation ;  but  a  very  different  result  follows  the  combination 
of  sugar  and  wines,  or  of  these  with  fruits.  The  vegetable 
acids  constitute  the  peccant  matter  both  in  fruit  and  wines. 
Those  goutiby  disposed  will,  therefore,  do  well  to  abstain,  as  a 
rule,  from  sweet  or  incompletely  fermented  wines,  fruits,  and 
sugar,  and  are  best  advised,  if  they  will  take  alcoholics,  to 
employ  either  a  little  matured  brandy  or  whisky,  well-diluted, 
or  some  genuine  and  sound  Bordeaux  wine,  also  diluted,  with 
one  meal  in  the  day,  presumably  at  dinner,  and  in  quantity  not 
exceeding  four  or  six  ounces.  Sometimes,  one  or  two  glasses  of 
mature  port  wine  agree  well  with  the  gouty.  The  point  of 
greatest  importance  is  for  the  patient  to  discover  for  himself 
what  best  agrees  with  him,  and  leaves  him  most  free  from 
gouty  symptoms.  It  is  found  that  one  wine  may  be  best  taken 
by  itself,  and  mixing  of  several  is  generally  harmful.  That 
which  suits  should  be  persevered  with,  and  regular  habits  as  to 
quantity  should  be  rigidly  maintained.  In  any  case,  the  quality 
of  the  wine  should  be  of  the  best ;  and  if  this  is  not  procurable, 
it  is  better  to  avoid  wine  altogether  and  take  matured  spirit 
with  water.  The  least  excess  is  harmful,  but  a  little  good  wine 
is  better  for  most  gouty  persons  than  water-drinking,  especially 
after  middle  life.  Changes  of  dietetic  habit,  and  interruptions 
to  the  ordinary  routine  are  apt  to  upset  digestion  and  to  deter- 
mine gouty  symptoms. 

Sugar  leads  by  fermentation  in  the  alimentary  canal  to  the 
formation  of  lactic  acid,  which  in  turn  is  decomposed  into  carbonic 
acid,  to  combine  with  sodium  and  potassium  salts.  As  pointed 
out  by  Dr.  Ralfe,  excess  of  lactic  acid  entails  excess  of  carbonic 
acid,  which  then  forms  acid  salts  of  these  bases,  with  acid  reactions, 
by  decomposition  with  neutral  salts. 

In  some  persons  farinaceous  food  in  excess,  or  what  is  for  them 


VEGETABLES.  429 

excess,  will  cause  too  free  production  of  uric  acid.  Hence,  the 
supply  of  bread  may  have  to  be  limited,  even  if  it  be  apparently 
well- digested. 

A  very  gouty  medical  friend  of  mine  declares  that  "  the  three 
poisons  for  gout  are  browned  fat,  grape-sugar,  and  alcohol." 

Certain  vegetables  are  injurious  to  the  gouty.  Amongst  these 
are  rhubarb,  tomatoes,  asparagus,  and  sorrel.  Some  gouty  persons 
can  partake  of  these  in  moderation,  while  others  are  soon  dis- 
turbed in  their  digestion,  and  suffer  vague  or  localized  pains  in 
consequence.  Vegetables  containing  acid  are,  as  a  rule,  harmful, 
and  if  sugar  be  taken  to  counteract  the  acid  quality,  the  combina- 
tion is  likely  to  be  still  more  noxious.  Cooked  tomatoes  appear 
to  be  less  well-borne  than  when  in  a  raw  state,  probably  because 
a  smaller  quantity  of  the  latter  is  apt  to  be  taken.  Asparagus  in 
moderation,  and  taken  at  intervals,  may  be  tolerated,  but  if  largely 
indulged  in  daily,  may  cause,  as  I  have  several  times  found, 
lumbar  pain  and  urinary  irritation.  Dr.  George  Harley  pointed 
out  that  glycosuria,  lasting  for  a  day  or  two,  and  in  one  case  for 
two  weeks,  may  be  sometimes  induced  by  asparagus  ;  and,  hence,  it 
may  be  presumed  that  the  liver  is  irritated  by  some  active  part 
of  the  plant,  whether  asparagin  or  aspartic  acid  is  not  known.1 
The  cruciferse,  if  well-digested,  are  harmless  and  wholesome,  and 
artichokes,  salsify,  celery,  onions,  and  beetroot  may  be  taken 
moderately  with  impunity.  Spinach  may  be  taken  with  advan- 
tage in  any  quantity  ;  turnips  are  harmless,  but  carrots  should  be 
taken  in  moderation.  Potatoes  should  not  be  too  freely  partaken 
of,  and  are  best  when  well  boiled  or  cooked  in  their  skins.  Fried 
and  mashed  potatoes  are  less  digestible.  Peas,  fresh  or  dried, 
and  beans  of  all  kinds,  in  moderation,  are  not  contra-indicated. 
Lettuce,  fresh  and  tender,  is  excellent,  but  must  not  be  taken 
unless  plain,  or  in  salad  with  oil  and  a  very  little  vinegar,  in 
French  fashion.      English  salads  are  unwholesome, 

Bice,  in  all  forms,  is  a  valuable  food  for  the  gouty,  and  sago 
and  tapioca  are  admissible,  provided  no  large  amount  be  taken  at 
any  one  meal.      Laver  is  unobjectionable. 

Pickled  vegetables  of  all  kinds  are  extremely  bad  for  the  gouty. 
Strongly  spiced  or  salted  foods,  seasonings  containing  vinegar, 
and  all  acid  things  are  to  be  carefully  avoided.  Mushrooms  and 
truffles  had  better  be  dispensed  with.      Most  varieties  of  nuts  are 

1  Boerhaave  noted  the  harmfulness  of  asparagus.  Van  Svvieten,  commenting  on 
this,  remarked  that  "healthy  people  may  eat  asparagus  in  any  quantity  ;  but  many 
gouty  people  who  have  eaten  largely  have  observed  it  to  hasten  the  paroxysm." 
Oxalate  of  calcium  crystals,  and  others  of  acicular  or  roughly  angular  form,  are  found 
in  asparagus. 


430  DRINKS    AND    DIETARY. 

harmful,  the  almond  being  hardly  an  exception,  unless  in  the  form 
of  fine  meal.  Chestnuts  are  perhaps  unobjectionable  if  well-cooked 
and  taken  in  moderation.  Fruits  and  wine,  as  commonly  taken 
together  at  dessert,  in  consequence  of  the  mingling  of  harmful 
vegetable  acids  and  alcohol,  are  highly  noxious  and  gout- inducing. 

Where  little  exercise  is  taken  and  little  brain-work  is  carried 
on,  the  dietary  may  be  more  largely  vegetable  and  less  animal 
and  nitrogenized.  The  latter  induces  increased  tissue-meta- 
bolism. Sedentary  habits  with  excess  of  food  cause  a  retention  of 
carbonic  acid  in  the  blood,  and  consequent  diminution  of  its 
alkalinity.  Excessive  muscular  exertion  leads  to  the  same  con- 
dition temporarily. 

Gouty  patients  are  very  apt  to  take  up  new  fashions,  and  to 
diet  themselves  unsuitably  according  to  some  prevalent  theory. 
They  are  generally  the  worse  for  these  practices,  and  do  them- 
selves harm  by  omitting  from  their  dietary  important  elements 
which  only  require  to  be  moderately  taken  to  prove  of  use  in 
their  general  nutrition.  Thus,  one  leaves  out  sugar,  another 
butter,  and  another  potatoes.  No  substitutes  for  these  articles 
can  be  supplied  with  the  same  advantage,  and  it  can  very  rarely 
be  necessary  to  forbid  entirely  the  use  of  any  one  of  them  for 
long  continuance. 

The  doctrinaire  in  medicine,  as  in  politics  or  other  matters,  is 
commonly  a  dangerous  person. 

In  respect  of  the  use  of  common  beverages  by  the  gouty,  there 
is  little  to  be  stated.  Whichever  is  best  digested  agrees  best  as  a 
rule.  A  caution  is  only  requisite  against  the  use  of  strong  tea  or 
coffee.  The  latter  is  objectionable  in  any  but  the  smallest  quantity 
immediately  after  dinner,  and  is  better  avoided  by  the  gouty. 
Sugar  should  be  sparingly  used,  either  with  tea,  coffee,  or  cocoa. 
As  a  rule,  weak  tea  and  cocoa  agree  best,  and  the  latter  is  an 
excellent  article  for  luncheon  for  those  who  eat  heartily  both  at 
breakfast  and  dinner,  and  therefore  require  no  animal  food  in  the 
middle  of  the  day. 

All  feeding  between  regular  meals  is  to  be  avoided,  and  no 
alcoholic  drinks  should  on  any  account  be  taken  at  other  than 
meal-times.  Much  harm  is  often  caused  by  beef-tea  and  other 
food  taken  at  intervals  by  people  who  feel  weak,  but  would  be 
refreshed  by  wholesome  occupation  or  exercise  in  the  open  air. 

These  remarks  apply  to  the  moderate  use  of  foods  and  drinks, 
and  have  no  bearing  on  excess  in  whatever  degree,  which  must 
always  be  reprobated,  and  especially  in  the  case  of  those  of  gouty 
heritage  or  proclivity. 


CHAPTER  XXIII. 

HYDROTHERAPY,  BALNEOTHERAPY  AND  SEA- 
BATHING IN  GOUT.  USES  OF  FRICTION  AND 
ELECTRICITY.  CLIMATIC  RESORTS  FOR  THE 
GOUTY. 

Amongst  the  most  potent  methods  for  the  prevention  and  removal 
of  gouty  ailments  must  certainly  be  reckoned  treatment  by  water- 
drinking  and  by  various  baths. 

The  value  of  hydrotherajoy  in  gout  has  been  known  from  very 
early  times.  The  more  accurate  knowledge  now  possessed  as  to 
the  intimate  nature  of  the  disorder  affords  at  once  a  better  explana- 
tion of,  and  a  fuller  warranty  for,  its  employment. 

I  have  hitherto  made  little  mention  of  this  method  of  treat- 
ment for  the  varieties  of  gout,  reserving  what  I  have  to  state  for 
more  complete  expression  in  this  chapter. 

Without  doubt,  the  best  results  are  commonly  gained  by  a 
combination  of  water-driuking  and  bathing,  and  to  these  methods 
must  be  added  the  valuable  practice  of  friction,  and  the  varieties 
of  muscular  exercise  which  are  usually  enjoined  at  the  same  time. 
Over  and  above  these  methods  there  remains  to  be  considered  the 
supreme  value  of  a  rightly  adapted  dietary  and  regimen,  which 
form  an  essential  part  of  the  course  pursued  at  every  well-ordered 
Spa.  Cases  of  gout  in  elderly  persons,  and  of  gouty  cachexia, 
are  altogether  unsuitable  for  hydrotherapy. 

Little  need  be  stated  respecting  the  value  of  a  resort  to  these 
stations  for  the  many  benefits  indirectly  due  to  them.  In  many 
cases  of  gout  it  is  important  to  secure  a  break  in  the  ordinary 
routine  of  life,  to  remove  the  patient  from  his  common  environ- 
ments and  habits,  to  provide  a  change  of  scene,  fresh  mental 
occupation,  and  a  holiday  in  the  true  sense  of  that  term.  The 
medicina  mentis  has  long  been  recognized  to  attach  itself  to 
hydrotherapy.  The  change,  in  most  cases,  should  afford  the 
enjoyment    of    a   better   climate,    though   it   may   often   involve 


432  HYDROTHERAPY. 

diminution  of  many  accustomed  comforts,  if  not  luxuries.  So 
many  gouty  patients  come  from  the  class  of  persons  who  are  daily 
exposed  to  luxury,  that  any  trifling  discomforts  or  privations 
experienced  may  often  be  reckoned  amongst  the  most  wholesome 
and  beneficial  influences  met  with  for  the  purpose  of  regaining 
health.  There  is  often  difficulty  in  urging  well-to-do  patients 
to  seek  the  health-resorts  that  are  best  suited  for  them,  because 
they  dread  the  discipline,  monotony,  and  ennui  attaching  to  the 
prescribed  course  of  treatment.  People  nowadays  travel  so  much 
and  so  far  afield,  that  they  not  seldom  have  larger  experience  of 
the  various  Spas  than  those  whom  they  consult,  and  whose  opinion 
they  would  fain  be  guided  by.  They  are  commonly  intolerant  of 
any  resorts  that  are  dull  and  little  frequented  by  their  country- 
men, however  good  they  may  be,  and  they  occasionally  rather 
seek  to  combine  the  exhausting  round  of  excitement  and  gaiety 
they  are  accustomed  to  at  home,  with  a  plan  of  treatment  as  little 
irksome  and  privative  as  possible. 

Such  a  pursuit  may  be  harmless  enough  for  such  persons  as 
are  not  seriously  ill,  but  where  there  is  disease  to  be  dealt  with, 
it  is  simply  impracticable,  and  the  physician  will  fail  in  his  duty 
if  he  consigns  his  patient  to  any  Spa  on  such  conditions.  There 
are  many  persons  whose  lives  are  very  dull,  and  such  as  to  leave 
little  time  for  pleasure  or  relaxation,  who  may  derive  great  benefit 
from  bright  and  lively  health-resorts,  and  who  would  be  wearied 
by  a  serious  course  with  all  that  is  necessarily  entailed  by  it.  But 
these  are  not  the  subjects  of  gouty  disease  in  any  intensity,  and 
do  not  call  for  consideration  in  the  present  connexion. 

At  the  outset,  it  is  worthy  of  note  that  mineral  waters  of  the 
most  varied  qualities  have  been  credited  with  valuable  properties 
for  those  goutily  disposed.  It  would  be  hard  to  explain  the 
alleged  usefulness  of  so  many  and  widely  differing  agents,  if 
there  was  but  one  object  in  view  in  urging  their  employment. 
The  fact  is  that  here,  as  in  all  therapeutic  efforts,  the  endeavour 
is,  or  ought  to  be,  to  cure  the  patient,  and  not  the  disease,  and 
to  effect  this  purpose  there  must  be  at  command,  as  in  the  case 
of  other  remedies,  a  variety  of  agents  to  meet  a  variety  of  con- 
ditions. I  have  tried  to  point  out  in  various  parts  of  this  treatise 
that  gout  is,  for  many  reasons,  a  very  different  malady  in  different 
individuals ;  that  its  phases  and  the  degree  of  its  impression  vary 
infinitely,  and  this  fact  must  be  duly  taken  note  of  in  hydro- 
therapy, as  in  any  other  mode  of  treatment.1 

1  Physicians  at  various  Spas  resorted  to  by  both  English  and  French  gouty  patients 
note  a  difference  in  the  effects  of  the  same  treatment  upon  persons  of  each  nation- 


HYDROTHERAPY.  433 

There  is  one  main  principle  which  underlies  all  hydrothera- 
peutic  efforts  in  the  case  of  the  gouty,  and  it  relates  to  what  may 
be  termed  a  "washing-out"  process.  Two  indications  should  guide 
all  forms  of  treatment  for  gouty  patients,  first,  the  elimination  of 
salts  of  uric  acid,  accumulation  and  stasis  being  thus  prevented  ; 
and  secondly,  the  re-establishment  of  the  general  health  on  as  high 
a  level  as  possible,  with  a  view  to  avert  the  recurrence  of  uric- 
hasruia,  especial  attention  being  paid  to  secure  full  vigour  of  all 
parts  of  the  nervous  system. 

The  first  indication  is  met  by  the  free  dilution  of  the  blood 
by  water,  and  alkalies  aid  in  rendering  this  organic  fluid  less 
acid  than  it  commonly  is  in  the  gouty.  A  more  complete  eli- 
mination of  uric  acid,  and  an  improved  hepatic  metabolism 
are  secured  by  saline  and  aperient  elements  in  some  of  the 
reputed  waters.  Adjusted  dietary,  friction,  and  exercise  aid 
further  in  attaining  these  ends.  The  second  indication  is  to 
be  met  by  recourse  after  the  depurative  method  to  such  a 
climatic  health-station  as  will  tend  to  invigorate  and  re-establish 
the  general  health. 

Bathing  comes  to  the  aid  of  the  gouty  by  reason  of  the  influ- 
ence of  thermal  mineralized  waters  on  recently  or  formerly  affected 
joints,  and  of  the  improved  action  of  the  sweat-glands,  which 
thenceforward  afford  much  depurative  relief,  and  assist  the  kidneys, 
the  latter  being  stirred  to  increased  work  by  the  water  taken 
internally.  Bathing  further  promotes  active  tissue-metabolism 
in  parts  less  completely  reached  by  water-drinking.  The  two 
methods  conjointly  carried  out  are  most  potent  in  promoting 
trophic  changes. 

Copious  water-drinking  is  proved  to  increase  metamorphosis  of 
nitrogenous  material  in  the  body.1  Within  certain  limits,  the 
assimilation  of  nitrogenous  substances  is  promoted.  The  quan- 
tity of  urine  and  of  its  nitrogen  is  increased  during  the  night. 
Too  copious  water-drinking  increases  the  weight  of  the  body,  and 
gives  rise  to  gastro-intestinal  and  cardiac  disturbances. 

Hot  water-drinking  is  now  frequently  practised  by  gouty  and 
other  patients,  and  I  have  known  excellent  results  follow  its  em- 
ployment. It  promotes  excretion  of  uric  acid  and  gravel.  Eight 
ounces  may  be  taken  on  rising  in  the  morning,  and  ten  to 
fourteen  ounces  late  at  night.     Many  gouty  manifestations  and 

ality.     A  greater  irritability  and  sensitiveness  is  observed  in  French  patients,  which 
is  not  so  manifest  in  the  English. 

1  Dr.  Jer.  Grigoriantz,  Inang.  Dissert.,  St.  Petersburg,  1 886.  Vide  Lond.  Med. 
Record,  November  15,  1S87. 

2  E 


434  WATER-DRINKING,  BATHS,  ETC. 

paroxysms  may  thus  be  averted,  and  threatenings  of  these  may 
sometimes  be  well- treated  by  adding  some  bicarbonate  of  potas- 
sium and  lemon-juice  to  the  water. 

Not  only  for  the  frail,  elderly,  and  cachectic  subjects  of  gout 
is  hydrotherapy  or  bath-treatment  contra-indicated.  It  is  also 
undesirable  where  serious  cardiac,  pulmonary,  or  renal  complica- 
tions exist,  and  must  be  avoided  during  any  active  gouty  process. 
Sydenham  declared  that  he  expected  no  good  to  be  gained  from 
mineral  waters  by  those  who  were  advanced  in  years,  phlegmatic, 
or  infirm. 

It  may  be  affirmed  that  the  indifferent  and  alkaline  waters  are 
available  rather  for  direct  treatment  of  gouty  symptoms,  and  of 
less  value  as  radical  remedies — that  is,  as  preventives — than  saline 
or  sulphureous  waters.  This  knowledge  has  only  been  widely 
spread  in  more  recent  years,  and,  hence,  may  be  explained  in  some 
measure  the  falling  off  in  attendance  at  many  of  the  purely  alka- 
line Spas,  while  that  at  the  alkali-saline,  saline,  and  sulphureous 
Spas  has  shown  tendency  to  increase. 

The  various  Continental  Spas  are  especially  attractive.  The 
more  complete  change  and  holiday  that  is  procurable  by  distance 
from  home,  amidst  novel  surroundings,  in  more  bright,  dry,  and 
sunny  climate,  avails  much.  The  arrangements  at  these  health- 
resorts,  too,  with  few  exceptions,  are  certainly  better  in  most 
particulars  than  those  to  be  found  in  this  country.  The  patients 
are  less  distracted  and  more  amenable  to  the  necessary  discipline. 
The  expense  in  most  instances  is  not  greater  than  that  entailed 
by  recourse  to  home  stations.  One  drawback  attaches  to  nearly 
all  such  places,  either  at  home  or  abroad,  namely,  their  unsuit- 
ableness  for  the  greater  portion  of  the  year,  and  especially  in  the 
winter  months.  I  know  of  but  one  winter  station  for  hydro- 
therapy in  England,  Bath,  and  two  or  three  only  are  practically 
available  at  this  season  abroad — Aix-la-Chapelle,  Dax,  and  Hamam 
ETrha  (in  Algeria).  Carlsbad  has  now  a  winter  season,  but  it 
will  be  difficult  to  persuade  patients  to  make  a  journey  from 
England  to  Bohemia  at  that  time  of  the  year. 

The  varied  qualities  of  the  waters  which  are  found  useful  in 
the  treatment  of  gout  and  of  gouty  ailments  are  truly  remarkable. 
There  are  for  this  purpose  at  least  eight  varieties  or  classes  of 
springs,  known  as  (i.)  Pure  and  indifferent;  (2.)  Alkaline;  (3.) 
Alkaline  and  saline;  (4.)  Bitter-acidulated;  (5.)  Saline;  (6.) 
Sulphureous ;  (7.)  Bromo-ioduretted ;  and  (8.)  Ferruginous. 
These  are  available  to  meet  all  the  requirements  of  gout  and 
gouty  states.      The  difficulty  is  to  deal  with  such  an  emharras 


PUKE  AND  INDIFFERENT  WATERS.      BUXTON.       BATH.       435 

de  richesses,  and  to  consign  each  case  to  a  station  that  shall  meet 
its  special  wants. 

It  may  be  affirmed  generally  that  hydropathic  treatment  is 
chiefly  available  for  such  persons  as  are  possessed  of  means  to 
benefit  by  such  treatment,  with  all  that  it  of  necessity  entails. 
Both  robust  and  weakly  patients  may  find  great  relief,  but  elderly 
persons  are  not,  as  a  rule,  able  to  undergo  either  the  fatigue  of 
travel  or  the  various  methods  which  must  be  enforced,  if  any 
benefit  is  to  be  derived  from  such  a  course. 

I  propose  to  discuss  the  use  and  value  of  each  variety  of  water 
already  mentioned  for  the  purposes  of  treatment  of  the  different 
forms  of  gout  and  gouty  ailments ;  and  for  greater  convenience 
my  remarks  shall  include  their  employment  both  in  the  form  of 
water-drinking  and  as  baths. 

1.  Pure  and  Indifferent  Waters — Of  these,  there  are  at  least 
a  hundred  recognized  by  authorities  on  the  subject.  Some  of 
them  are  cold,  others  thermal.  The  best  known  and  most  fre- 
cpiented  Spas  are  Malvern,  Bristol,  Bath,  Buxton,  Clifton,  Plom- 
bieres,  Gastein,  Schlangenbad,  Teplitz,  Pfeffers,  Wildbad,  and 
Ragatz.  The  thermal  springs  of  Buxton,  Bath,  Schlangenbad, 
Wildbad,  Gastein,  Plombieres,.  Pfeffers,  and  Teplitz  are  all  avail- 
able for  baths. 

Buxton  (Derbyshire). — Buxton  occupies  a  very  important  place 
on  this  list.  Its  position,  1000  feet  above  the  sea,  well  inland, 
with  a  dry  soil  and  bracing  climate,  affords  all  the  favouring  con- 
ditions demanded  in  a  sanitary  station  for  the  treatment  of  gout 
in  the  summer  season. 

A  marked  feature  of  the  Buxton  spring  is  the  large  amount 
of  nitrogen  gas  (ninety-nine  per  cent.)  contained  in  it,  and  the 
absence  of  oxygen  gas.  The  water  issues  at  a  temperature  of  8  ii° 
F.,  and  requires  to  be  farther  heated  for  baths.  The  best  and 
latest  analysis  of  it  is  that  of  Dr.  Thresh,1  who  is  of  opinion  that 
much  of  the  potency  of  its  healing  virtue  is  due  to  the  large 
quantity  (twenty-four  volumes  in  a  thousand)  of  nitrogen  gas  in 
a  semi-nascent  state.  Dr.  Munk  has  pointed  out  that  the  waters 
of  Gastein  and  Wildbad  are  also  rich  in  this  element,  though  to 
a  far  less  degree  than  that  of  Buxton,  and  this  fact  is  important, 
and  worthy  of  further  study. 

Buxton  water  has  a  detergent  and  softening  action  on  the 
skin,  is  free  from  odour  and  taste,  and  has  a  faintly  blue  colour. 
It  was  certainly  used  more  than  three  centuries  ago  in  the  treat- 
ment of  arthritic  diseases.  Patients  remain  about  ten  minutes  in 
1  Buxton  as  a  Health-Resort.     By  John  C.  Thresh,  D.Sc.    1883. 


436  WATER-DRINKING,  BATHS,  ETC. 

the  bath.  The  water  has  a  diuretic  action.  Many  cases  of  all 
forms  and  stages  of  gout  derive  great  benefit  from  a  course  at 
Buxton,  and  secure  freedom  from  subsequent  paroxysms  in  a 
marked  degree.  Advanced  cases  occurring  in  persons  with 
constitutions  broken  down  by  excesses  are  not  much,  if  at  all, 
benefited  by  Buxton,  or  by  any  form  of  Spa  treatment. 

Cases  of  saturnine  gout  in  early  stages  derive  much  advantage 
from  treatment  by  indifferent  waters.  In  advanced  stages  with 
renal  cirrhosis  and  anasmia,  no  benefit  is  to  be  expected  from 
hydrotherapy. 

During  acute  paroxysms  no  form  of  water-treatment  is  to 
be  practised,  but  as  soon  as  the  parts  are  free  from  all  active 
symptoms,  bathing  is  desirable.  Great  benefit  is  derived  in  all 
cases  of  incomplete  gout.  An  acute  attack  sometimes  supervenes 
during  a  course  of  baths  or  water- drinking  which  may  bring  relief, 
but  it  may  be  possible  to  avoid  this  by  concurrent  medicinal 
treatment,  and  no  such  attack  can  be  considered  a  desideratum. 
In  most  cases  the  patients  should  both  drink  the  waters  and 
bathe. 

Bath  (Somersetshire). — Bath  is  available  in  winter  and  spring. 
The  Berthollet  (natural  vapour)  bath,  as  employed  at  Bath,  is 
a  very  efficient  aid  in  the  cure.  Acute  gouty  arthritis  may  be 
thus  treated.  It  may  be  used  generally  or  locally,  and  com- 
bined with  douches  and  frictions.  Hot  douches  may  be  used 
where  immersion  is  found  undesirable.  It  is  found  best  to 
alternate  baths  with  friction  every  other  day,  this  plan  being 
less  exhausting  to  the  patient.  The  details  of  treatment  are, 
however,  always  best  left  in  the  hands  of  the  local  medical 
advisers,  whose  experience  constitutes  the  greatest  safeguard  in 
each  case  ;  such  details  relate  to  habits  of  diet,  exercise,  and 
general  regimen  during  a  sojourn  at  any  Spa. 

As  a  rule,  it  may  be  laid  down  that  treatment  by  the  indif- 
ferent waters  is  best  adapted  for  such  persons  as  are  not  robust 
and  gross  in  habit,  for  cases  of  strongly  marked  gouty  heredity, 
where  there  is  often  an  asthenic  character  in  all  the  phases  of  the 
disorder. 

Plombieres  (Vosges). — The  waters  of  Plombieres  are  chiefly 
used  in  the  form  of  baths,  but  are  also  taken  internally.  The 
Bain  des  Capucins  there  was  formerly  called  the  Bain  des  Gout- 
teux.  Cases  of  gout  in  which  nervous  erethism  is  a  marked 
feature  are  reported  to  be  much  benefited  at  this  station,  also 
cases  of  visceral  neuralgia  and  sciatica.  Varieties  of  douches  are 
much  employed,  and  the  Etuves,  or  hot  chambers,  are  valuable 


ALKALINE   WATERS.       VICHY.       NEUENAHE.  437 

adjuncts.  The  water  is  but  slightly  mineralized,  calmative  in  its 
action,  and  of  high  temperature,  159°  F.  The  bathing  arrange- 
ments are  very  complete,  and  the  neighbourhood  is  attractive. 

Wildbad,  Teplitz,  Gastein,  Leuk,  Pfeffers,  and  Schlangenbad  are 
all  available  sources  for  cases  of  the  class  just  indicated.  The 
high  altitudes  of  many  of  these  Spas  constitute  one  of  their  most 
noteworthy  features,  and  doubtless  prove  useful  in  promoting 
recovery  from  gouty  states.  Cases  in  which  crippling  and  defor- 
mities of  joints  are  prominent  symptoms  mostly  do  well  under 
the  varieties  of  treatment  provided  at  any  of  them.  It  is  usually 
advisable  to  send  patients  to  some  subalpine  station  after  a  course 
of  bathing  in  thermal  waters.  Garrod  recommends  a  course  of 
the  Elizabeth  spring  at  Homburg  after  treatment  at  Wildbad. 
Distilled  water,  plain  or  charged  with  carbonic  acid  gas,  is  very 
useful  for  the  goutily  disposed,  and  may  often  be  drunk  with 
advantage. 

2.  Alkaline  Waters. — There  are  many  Spas  affording  alkaline 
waters.  Those  most  suitable  for  gouty  cases  are  Vichy  (which 
may  be  considered  the  most  typical  alkaline  Spa),  Evian-les-Bains, 
Neuenahr,  Tarasp-Schuls,  Vittel,  and  Royat.  Some  of  these  are 
strictly  alkali-saline  waters. 

Vichy  (Allier). — Vichy  is  one  of  the  most  reputed  resorts. 
The  waters  contain  principally  sodium  bicarbonate,  about  forty 
grains  in  the  pint,  and  vary  in  temperature  from  2  1  °  F.  to  iii° 
F.  The  Celestins  spring  is  the  most  valuable.  They  are  best 
taken  during  the  intervals  between  attacks  of  gout ;  but,  in 
common  with  all  strongly  impregnated  waters,  whatever  be  the 
main  ingredients,  are  unsuitable  in  cases  of  atonic  gout,  and  for 
pallid  and  weakly  patients.  Alkaline  waters  are  especially  indi- 
cated in  the  case  of  robust  patients  who  suffer  from  hepatic 
troubles  connected  with  gout.  Thus,  they  are  useful  in  glycosuria 
and  in  the  class  of  gouty  diabetic  patients  who  are  often  stout. 

In  gastro-enteric  catarrh,  with  coated  tongue  and  loaded  urine, 
a  course  of  treatment  at  Vichy,  including  bathing,  often  proves 
highly  serviceable.  Renal  calculi  are  sometimes  passed  during 
such  a  course.  It  has  often  been  asserted  that  the  Vichy  waters 
are  debilitating.  This  is  denied  by  M.  Durand-Fardel,  who  has 
practised  there  for  more  than  forty  years.  Garrod  believes  that 
tophaceous  deposits  are  liable  to  be  increased  by  them. 

Neuenahr  (Prussia). — Neuenahr  is  in  worthy  repute  for  treat- 
ment of  gouty  glycosuria. 

Evian-les-Bains  (Haute-Savoy). — Evian-les-Bains  is  a  very 
favourable  station  for  the  gouty.      It  is  chiefly  resorted  to  by 


438  WATER-DRINKING,  BATHS,  ETC. 

French  patients.  Its  position  on  the  Lake  of  Geneva,  1 1  50  feet 
above  the  sea,  is  all  that  can  be  desired.  The  waters  are  diuretic 
and  sedative,  and  of  especial  value  in  gouty  affections  of  the 
abdominal  viscera. 

Tarasp-Schuls  (Engadine). — Tarasp-Schuls,  in  the  Engadine, 
is  also  an  elevated  mountain  station.  The  Lucius-Quelle  contains 
almost  as  much  sodium  bicarbonate  as  the  waters  of  Vichy,  but 
has  sodium  chloride  and  sulphate  in  addition.  The  temperature 
is  43°  F.  Evian-les-Bains  and  Tarasp-Schuls  may  be  visited 
after  a  course  at  Homburg,  Carlsbad,  Vichy,  or  Kissingen,  and 
for  such  resort,  their  climates  may  be  sufficiently  effectual  without 
recourse  to  hydropathic  treatment. 

Vittel  (Vosges). — Vittel  is  available  for  gouty  dyspepsia, 
diabetes,  urinary  gravel,  and  cystitis,  and  for  the  same  classes 
of  cases  as  find  benefit  at  Contrexeville.  There  is  less  lime  and 
more  magnesia  in  Vittel  than  in  Contrexeville  water.  Excretion 
of  uric  acid  is  promoted  in  a  very  marked  manner,  as  has  been 
proved  by  Dr.  Paul  Eodet.  Cases  of  gout  with  gastro-intestinal, 
renal,  nervous,  and  atonic  manifestations  do  well  at  Vittel. 
Gouty  diabetes  may  be  effectually  treated  there.  It  is  advised 
that  the  water  should  be  used  every  second  month  for  some  time. 
Three  or  four  glasses  of  the  Grande  Source  may  be  taken  daily, 
with  or  between  meals. 

E.OYAT  (Auvergne). — Royat  has  become  an  important  resort 
for  sufferers  from  many  phases  of  gout.  It  is  best  adapted  for 
asthenic  and  chronic  cases,  and  for  the  treatment  of  gouty  skin- 
disorders,  chronic  catarrhal  pharyngitis  and  laryngitis.  The 
waters  are  of  the  same  temperature  as  that  of  Buxton,  83°  F. 
Both  drinking  and  bathing  are  practised. 

Contrexeville  (Vosges). — Contrexeville  is  now  an  important 
resort,  its  waters  having  gained  much  reputation  in  the  treat- 
ment more  especially  of  renal  calculi  and  gravel.  Its  altitude  is 
1000  feet  above  the  sea-level,  and  the  climate  is  sufficiently 
bracing.  The  waters  issue  at  a  temperature  of  53°  F.,  and 
contain  calcium  bicarbonate  and  sulphate,  with  magnesium  sul- 
phate and  traces  of  lithium  and  iron.  They  are  of  especial 
value  in  cases  of  chronic  and  atonic  gout.  Their  action  is  laxa- 
tive, diuretic,  and  tonic,  and,  hence,  they  are  better  adapted  to 
many  phases  of  gouty  disorders  than  those  of  Carlsbad  or 
Vichy.  Gouty  diabetes  is  efficiently  treated  here.  All  forms  of 
urinary  gravel,  cystitis,  and  biliary  lithiasis  may  derive  benefit 
at  Contrexeville,  some  of  the  results  being  very  noteworthy  and 
satisfactory. 


CONTREXEVILLE.       DAX.       MUD-BATHS.  439 

Objections  are  made  to  the  employment  of  waters  containing 
so  much  lime  salt  as  is  to  be  found  in  those  of  Evian,  Contrex^- 
ville,  Vittel,  and  others.  No  full  explanation  of  the  benefits 
derived  from  recourse  to  such  waters  is  yet  forthcoming,  but 
there  can  be  no  doubt  of  the  value  of  treatment  by  them,  despite 
the  apparent  contra-indication  of  lime  salts  in  calculous  disorders 
originating  from  uric  acid,  and  in  most  forms  of  gout.  The  fact 
that  large  quantities  of  uric  acid  sand  are  passed  within  a  few 
days  of  direct  treatment  by  these  waters  cannot  be  gainsaid,  and 
I  know  of  no  other  equally  effective  method  for  procuring  such 
elimination  as  is  secured  by  this  method.  It  is  perhaps  still 
more  extraordinary,  as  against  preconceived  ideas,  that  alkaline 
mineral  waters,  having  lime  as  a  base,  should  prove  highly 
effective  in  the  treatment  of  oxaluria ;  but  such  is  the  case,  as 
is  proved  by  large  experience  at  Contrexeville. 

Dax  (Landes,  France). — This  is  an  important  station,  the  old 
Roman  Aqua  Augusta,  but  as  yet  little  frequented  by  English 
patients.  The  waters  much  resemble  those  of  Bath,  Buxton, 
and  Plombieres.  They  are  thermal,  162°  F.,  and  contain  calcic, 
magnesium,  sodium,  and  potassium  sulphates,  the  chlorides  of 
these  bases,  also  iron,  manganese  iodine,  and  bromine.  Carbonic 
acid,  oxygen,  and  nitrogen  gases  are  evolved  from  them.  There 
are  also  sulphur  and  iron  waters.  The  bathing  arrangements  are 
excellent,  and  the  climate  mild.  Treatment  may  be  carried  out 
in  winter  with  advantage,  and  many  varieties  of  gouty  ailments 
may  derive  benefit  here.  The  vegeto-mineral  mud-baths  are  of 
great  utility,  and  hot  mud  is  applied  locally  to  affected  joints. 
Unfortunately,  the  accommodation  for  the  full  comfort  of  patients 
is  not  up  to  the  requirements  of  the  present  day,  but  this  will 
doubtless  soon  be  rectified. 

Amongst  simple  alkaline  and  slightly  saline  waters,  those  of  a 
portable  class,  much  used  as  table-waters,  may  be  here  referred  to. 

The  best  of  these  are  the  Nassau  Niederselters,  St.  Galmier, 
Apollinaris,  Giesshubel,  Kronenquelle,  and  Vals  waters.  Some  of 
these  are  largely  consumed,  and  are  of  particular  value  when 
ordinary  drinking-water  is  either  hard,  or  of  uncertain  quality  as 
to  sewage -contamination.  Vals  water  is  somewhat  similar  to, 
but  weaker  in  soda  salts  than,  Vichy  water,  and  has  a  slightly 
chalybeate  taste. 

3.  Alkaline  and  Saline  Waters. — Of  these  there  are  many  varie- 
ties. The  best  known  are  those  of  Carlsbad,  Marienbad,  Kronthal, 
and  Brides.  Vichy  and  Royat,  already  alluded  to,  are  strictly 
placed  in  this  category. 


44-0  WATER-DRINKING,  BATHS,  ETC. 

Carlsbad  (Bohemia). — Carlsbad  has  long  been  held  in  repute 
as  one  of  the  best  stations  for  the  hydropathic  treatment  of  many 
phases  of  gout,  and  there  is  ample  proof  of  the  value  of  its  waters 
in  such  cases.  It  is  properly  a  resort  for  those  of  vigorous  con- 
stitution whose  textures  are  as  yet  free  from  marked  degenerative 
change,  and  whose  gouty  manifestations  are  of  a  sthenic  character. 
The  waters  are  thermal  and  mainly  charged  with  sodium  salts, 
the  sulphate,  chloride,  and  carbonate  predominating.  Their 
action  is  aperient  and  diuretic,  and  the  urine  is  rendered  alkaline 
by  them.  During  the  course  of  treatment  an  aperient  action 
is  not  specially  sought,  nor  is  such  necessary  to  secure  the  full 
benefits  of  the  waters.  Uratic  deposits  are  found  in  the  urine. 
Cases  of  gastro-enteric  disturbance  and  hepatic  derangements, 
including  biliary  lithiasis  and  glycosuria,  are  suitable  for  Carlsbad 
treatment.  A  careful  dietary  forms  an  essential  part  of  the 
course,  which  lasts  for  three  weeks,  but  the  German  compotes 
should  be  avoided.  The  Sprudel  spring  is  used  for  baths,  with  or 
without  peat.  Patients  commonly  lose  weight  under  treatment, 
and  this  may  occur  to  a  serious  extent  unless  due  care  be  taken. 
It  is  proper  to  follow  up  the  course  by  a  residence  at  some  high 
or  subalpine  station,  of  which  many  suitable  ones  may  be  found 
in  Switzerland,  Ragatz  being  a  favourite,  also  Seelisberg. 

Carlsbad  water  should  be  taken  from  time  to  time  after  the 
course,  and  the  best  results  follow  a  succession  of  visits  to  the 
Spa.  Patients  are  well-advised,  I  believe,  to  resort  for  three  seasons 
of  treatment.  In  some  cases  it  is  desirable  to  prescribe  an  early 
summer  and  an  autumnal  course  in  the  same  year.  The  waters 
may  be  beneficially  taken  at  home  with  a  suitable  dietary  and 
regimen,  but  it  is  seldom  possible  to  secure  the  necessary  dis- 
cipline and  attention  to  details  amidst  the  claims  and  duties  of 
home-life. 

Carlsbad  may  certainly  be  pronounced  one  of  the  best  and 
most  useful  Spas  for  the  robust  classes  of  gouty  patients. 

Marienbad  (Bohemia). — The  waters  of  this  Spa  are  very  similar 
to  those  of  Carlsbad.  The  station  has  the  advantage  of  greater 
altitude,  being  over  1900  feet  above  the  sea,  or  600  feet  higher 
than  Carlsbad.  Forests  of  pine  surround  both  places.  It  is  not 
so  much  frequented  for  the  treatment  of  purely  gouty  cases,  but 
the  waters  of  the  Kreuz  and  Ferdinand  springs  are  equally  avail- 
able with  those  of  Carlsbad  for  many  phases  of  irregular  and 
incomplete  gout.  Mud  (ferruginous  peat)  baths  are  used,  and 
whey  of  goats'  milk  is  much  employed  in  the  course.  Cases 
of   obesity,  hepatic   disease    with   portal   plethora,    hemorrhoidal 


BITTER   AND    SALINE    WATERS.  44 1 

tendency,  and  uterine  disorders  are  very  efficiently  treated 
here. 

Kronthal  (Nassau). — Kronthal  is  a  favourable  station  for 
disorders  of  mucous  surfaces.      The  waters  are  cold. 

Brides- les-Bains  (Savoy). — This  is  one  of  the  best  mountain 
stations  for  summer  resort.  It  is  situated  1800  feet  above  the 
sea-level  amidst  beautiful  surroundings.  The  waters  are  thermal 
(95°  F.),  and  contain  chiefly  sodium  salts  with  some  magnesium 
and  lime,  also  a  little  iron.  They  are  diuretic  and  slightly 
aperient.  In  cases  of  chronic  gout,  hepatic  congestion,  gouty 
affections  of  the  abdominal  viscera,  in  diabetes  and  calculous 
nephritis  and  cystitis,  they  are  of  great  service. 

Patients  may  go  to  Brides  with  advantage  after  the  course 
at  Aix-les-Bains. 

Salins-Moutiers  (Savoy). — Salins-Moutiers,  two  miles  and  a 
half  distant,  1500  feet  above  the  sea-level,  over  a  road  com- 
manding magnificent  mountain-scenery,  possesses  invigorating 
springs.  The  waters  are  gaseous,  hot  (95°  F-),  and  contain 
much  iron  and  arsenic  in  the  deposits,  also  small  quantities  of 
bromine  and  iodine.  Patients,  however,  taking  the  course  at 
Salins  usually  reside  at  Brides,  where  there  is  better  accommodation. 

Both  of  these  stations  will  probably  soon  become  better  known 
and  frequented. 

4.  Bitter  Acidulated  Waters. — These  are  used  as  medicinal 
agents,  and  their  sources  are  not  resorted  to. 

Ofen  or  Buda  Group  of  Bitter  Waters  (Hungary) — Rubinat 
(Spain) — Pullna  (Bohemia). — The  water  of  Epsom  in  this 
country  is  the  type  of  these.  The  best  known  are  those  of 
Hunyadi  Janos,  Friedrichshall,  ^Esculap,  Bubinat,  and  Pullna. 
All  of  these  are  now  used  in  domestic  practice,  or  employed 
at  other  Spas  for  their  special  aperient  and  depurative  effects. 
They  are  best  taken  with  an  equal  quantity  of  hot  water  early  in 
the  morning. 

5.  Saline  Waters. — Of  these  a  large  variety  is  at  command. 
Some  of  the  best  included  in  this  class  contain  other  than  saline 
ingredients,  such  as  sulphur  and  arsenic. 

Amelie-les-Bains  (Pyrenees). — Amelie-les-Bains  is  700  feet 
above  the  sea-level,  and  has  thermal  waters  of  sulphureous  sodic 
character.  It  is  frequented  by  patients  suffering  from  cutaneous 
and  respiratory  disorders. 

Baden-Baden  (Duchy  of  Baden). — Baden-Baden  is  an  attrac- 
tive station,  in  high  repute  for  all  classes  of  arthritic  cases,  arid 
especially  for  those  of  gouty  and  rheumatic  origin.     The  arrange- 


442  WATER-DRINKING,  BATHS,  ETC. 

meiits  are  very  perfect,  and  the  waters  are  thermal,  varying  from 
iio°  F.  to  i6i°  F.,  containing  chiefly  chlorides  of  sodium, 
potassium,  and  magnesium,  with  calcic  sulphate  and  a  little  iron. 
The  Fettquelle  and  the  Murquelle  springs  also  contain  lithium  in 
larger  amount  than  is  found  in  any  other  mineral  water.  Cases 
of  chronic  and  atonic  gout  derive  benefit.  The  climate  is  very 
hot  in  summer,  and  a  more  bracing  station  should  be  sought 
after  a  course  of  the  waters. 

Bagneres  de  Bigorre  (Hautes-Pyrenees). — Bagneres  de  Bi- 
gorre  is  a  favourite  bathing-station,  1750  feet  above  the  sea- 
level.  The  waters  are  thermal,  saline,  arsenical,  sulphureous,  and 
ferruginous.  It  may  be  visited  in  winter,  but  the  high  season  is 
from  June  to  September. 

La  Bourboule  (Auvergne). — La  Bourboule  possesses  effer- 
vescent saline  arsenical  waters  of  high  thermality,  and  is  of 
great  service  in  gouty  cases  with  skin-disorders  and  neurotic 
manifestations.  Diabetics  are  well-treated  here.  The  waters 
are  portable,  and  may  be  used  at  home.  The  bathing  arrange- 
ments are  now  very  complete.  Chlorides  and  carbonate  of  sodium 
are  largely  present  in  the  water,  and  each  litre  contains  the 
equivalent  of  twenty  minims  of  Fowler's  solution  of  arsenic.  It 
has  been  called  "  Veau  arsenicale  par  excellence."  La  Bourboule  is 
also  as  valuable  a  resort  for  strumous  as  for  gouty  patients,  and 
children  derive  great  benefit  from  the  waters. 

Ems  (Duchy  of  Nassau). — Ems,  though  a  favourite  station,  is 
little  frequented  by  gouty  patients.  The  climate  is  relaxing,  but 
elderly  patients  may  be  benefited  here.  The  waters  are  found 
useful  in  cases  of  migraine  due  to  uric  acid  disturbances,  palpita- 
tion, and  some  gouty  skin-affections.  For  gouty  bronchitis  and 
asthma  it  is  certainly  one  of  the  best  stations.  Lithiasis,  cystitis, 
and  diabetes  are  also  well-treated  at  Ems,  as  also  cases  of  con- 
gestive dysmenorrhea,  menorrhagia,  and  chronic  uterine  catarrh. 

The  waters  are  all  rich  in  alkaline  chlorides,  and  thermal. 
All  forms  of  baths  and  inhalations  are  available. 

Harrogate  (Yorkshire). — Harrogate  is  one  of  the  best  and 
most  widely  useful  of  our  English  Spas.  I  refer  here  to  the 
saline  sulphur  waters,  which  owe  as  much  of  their  virtues  to 
their  saline  as  to  their  sulphureous  properties.  These  are  non- 
thermal, like  all  Harrogate  waters,  but  are  artificially  heated  for 
use.  Barium,  strontium,  iodine,  bromine,  and  calcium  chloride 
are  found  in  small  amounts,  while  calcium  sulphate  is  in  but 
small  quantity. 

These  waters  are  valuable  in  chronic  gout,  hepatic  congestion 


ISCHL.       HOMBURG.       KISSINGEN.  443 

with  constipation,  and  bronchitis.  In  chronic  eczema,  prurigo, 
and  psoriasis  they  rank  second  to  none  in  usefulness.  Gravel 
and  lithiasis  are  well-treated  here.  As  an  inland  station,  with  a 
bracing  climate  in  summer,  Harrogate  has  strong  claims  for 
attention  for  many  phases  of  gouty  disorder,  and  the  arrange- 
ments are  excellent  and  attractive. 

Ischl  (Austria). — Ischl  is  situated  1600  feet  above  the  sea- 
level  amidst  charming  surroundings.  The  waters  are  cold, 
saline,  and  sulphureous.  All  varieties  of  baths  are  available, 
and  the  classes  of  cases  suitable  for  treatment  include  disorders 
of  the  digestive  organs,  chronic  skin-diseases,  uterine  ailments, 
and  nervous  derangements. 

Homburg  (Hessen-Nassau). — Homburg-les-Bains  is  one  of  the 
Spas  now  most  largely  frequented  for  all  purposes.  The  waters 
are  saline,  acidulous,  and  ferruginous,  richest  in  sodium  chloride, 
and  contain  magnesium. and  calcic  chloride  and  carbonate,  with 
some  sodium  sulphate.  The  arrangements  are  as  complete  as 
possible,  and  the  place  is  attractive,  bracing,  and  salubrious. 

Treatment  at  Homburg  is  of  especial  value  for  atonic  gout 
with  hepatic  and  digestive  disturbance.  Peat,  pine-extract,  and 
other  baths  are  given.  Garrod  recommends  a  course  at  Homburg, 
either  before  or  after  one  at  Wildbad  or  Aix-les-Bains. 

Kissingen  (Bavaria). — This  is  justly  a  very  favourite  resort, 
possessing  five  springs,  mostly  rich  in  sodium  and  magnesium 
chloride  and  magnesium  and  calcium  sulphate.  The  tempera- 
ture is  between  6o°  and  70°  F.,  and  the  waters  are  warmed 
before  drinking.  Their  action  much  resembles  that  of  Hom- 
burg waters,  and  is  available  for  the  same  classes  of  cases. 
The  district  around  is  salubrious  and  attractive,  and  the  general 
arrangements  excellent.  The  baths  are  of  great  value,  especially 
the  Soole  water,  peat,  and  gas  (carbonic  acid)  baths.  Diabetic 
patients  are  as  well-treated  here  as  at  Carlsbad,  and  cutaneous 
disorders  also  derive  much  benefit.  After  the  course  the  Eakoczy 
water  may  be  continued  for  some  time.  It  is  portable,  and  may 
be  taken  at  home. 

Capvern  (Hautes-Pyrenees). — These  waters  are  cold,  and  con- 
tain chiefly  calcium  sulphate.  They  are  especially  useful  for  cal- 
culous disorders,  and  are  much  resorted  to  by  patients  from  the 
South  of  France.      They  much  resemble  those  of  Vittel. 

Pougues  (Loire,  France). — This  station  has  an  altitude  of  780 
feet.  The  waters  are  highly  carbonated,  calcic,  magnesium, 
sodium,  and  iron  bicarbonates,  with  calcic  and  sodium  sulphates, 
magnesium  chloride  being  also  contained  in  them.     The  arrange- 


444  WATER-DRINKING,  BATHS,  ETC. 

ments  are  very  complete.  Various  dyspeptic  ailments  are  well- 
treated  here,  and  the  place  is  highly  appreciated  by  French  patients. 

Chatel-Guyon  (Auvergne). — This  is  a  new  station,  sometimes 
called  the  "  Kissingen  of  France."  The  waters  are  thermal,  95° 
F.,  gaseous,  and  contain  sodic  and  magnesium  chlorides,  calcic, 
sodium,  iron,  lithium,  and  potassic  bicarbonates.  Patients  some- 
times resort  here  after  a  course  at  Eoyat.  The  action  of  the 
waters  is  aperient  and  diuretic.  Digestive  disturbances,  hgenior- 
rhoidal  tendency,  and  cases  of  headache  and  melancholia  are 
benefited  here. 

Wiesbaden  (Nassau). — This  Spa  is  largely  resorted  to,  and  has 
a  deserved  reputation  in  the  treatment  of  many  phases  of  gout. 
The  springs  are  thermal,  1 60 °  F.,  rich  in  chlorides  of  many  bases, 
also  in  calcic  carbonate,  but  essentially  saline.  Their  action 
is  diuretic  and  slightly  aperient,  and  is  best  adapted  for  languid 
patients  with  crippling,  who  present  no  marked  signs  of  visceral 
decay.    The  baths,  taken  under  strict  supervision,  are  of  great  use. 

Hammam  R'Irha  (Algeria). — This  is  a  station  of  importance, 
especially  because  it  is  available  in  winter.  The  climate  and 
scenery  are  charming.  There  are  two  springs,  one  thermal,  one 
containing  calcic  sulphate,  105°  F.,  and  the  other  cold,  impreg- 
nated with  bicarbonate  of  iron,  45°  F.  The  arrangements  are 
good,  and  living  is  not  costly.  An  inspection  of  the  baths  and 
system  pursued  here  led  me  to  form  a  high  opinion  of  this  place. 
There  are  several  similar  establishments  in  Algeria. 

Leamington  (Warwickshire). — This  spa  has  several  powerful 
waters.  The  Old  Well  water  is  impregnated  with  sodic  and  calcic 
chlorides,  sodic  sulphate,  and  is  charged  with  carbonic  acid. 
The  saline  chalybeate  water  is  more  powerful. 

Cheltenham. — This  station  has  a  variety  of  waters,  saline, 
saline  aperient,  and  ioduretted  and  sulphur  springs. 

Llandrindod  (Radnorshire). — (a.)  Saline,  (&.)  sulphureous,  (c.) 
chalybeate.  The  old  saline  spring  at  this  Spa  is  of  undoubted 
usefulness  in  many  forms  of  arthritic  ailment,  and  has  been 
employed  for  two  centuries.  It  contains  440  grains  of  mineral 
constituents  in  the  gallon,  consisting  chiefly  of  sodium,  magnesium, 
and  calcium  chloride,  with  potassium  salts.  The  water  is  ather- 
mal,  laxative,  diuretic,  and  alterant ;  and  being  portable  and 
aerated  before  being  bottled,  may  be  drunk  at  home,  either  with 
milk  or  as  a  table-water.  It  much  resembles  Homburg  saline 
water.      There  are  also  sulphur  and  chalybeate  springs. 

Saratoga  (New  York  State). — Saratoga  is  one  of  the  best  of 
the  American  Spas.      The  waters  are  cold,  and  have  the  merit  of 


SULPHUREOUS   WATERS.  445 

being  very  palatable.  Saratoga  is  (as  I  can  testify  after  several 
visits)  salubrious  and  sufficiently  attractive.  The  waters  are 
slightly  aperient.  The  dietetic  discipline;  necessary  for  gouty 
patients  is,  perhaps,  hardly  enforced  as  it  should  be,  but,  as  a 
matter  of  fact,  there  are  not  as  yet  many  truly  gouty  patients  in 
the  United  States  to  make  use  of  the  course. 

Uriage  (near  Grenoble,  France). — Uriage  possesses  one  of  the 
best-ordered  thermal  establishments  in  France.  The  waters  are 
saline,  slightly  arsenical  and  sulphureous,  with  a  temperature  of 
8 1  °  F.  Their  use  is  adapted  to  the  class  of  cases  for  which 
Harrogate  is  available,  skin-disorders,  eczema,  herpes,  and  psoriasis 
being  well-treated  here.  The  place  is  largely  resorted  to,  bath- 
ing being  vigorously  carried  on. 

St.  Clair  Springs  (Michigan,  U.S.A.). — There  are  two  springs 
here,  and  a  good  establishment  in  the  Oakland  Hotel.  The 
alkaline  chloride  is  most  employed,  but  the  sulphur  chalybeate  is 
also  available.  These  were  discovered  iooo  feet  down  while 
boring  for  petroleum.  The  springs  are  largely  resorted  to  by 
American  and  Canadian  patients.  An  inspection  of  them  in 
1886  led  me  to  form  a  high  opinion  of  these  waters. 

6.  Sulphureous  Waters. — The  main,  indications  for  the  employ- 
ment of  sulphureous  waters  in  gout  are  chronicity  and  want 
of  tone.  Skin-affections  commonly  derive  great  benefit,  espe- 
cially psoriasis,  dry  eczema,  prurigo  of  all  varieties,  and  acne. 
Muscular  pains,  stiff  joints,  cramps,  and  many  aches  of  the  gouty, 
often  called  "  rheumatic,"  are  oftentimes  remarkably  amenable  to 
treatment  by  sulphur,  both  externally  and  internally.  Portal 
congestion,  constipation,  and  hgemorrhoidal  tendency  are  also 
markedly  under  the  influence  of  sulphureous  treatment,  hydro- 
therapeutic  or  otherwise. 

Sulphur  is  held  in  but  feeble  combination  in  the  various  sul- 
phureous mineral  waters  in  the  form  of  sulphides  of  calcium, 
magnesium,  and  hydrogen.  In  Germany  sulphur  has  long  been 
used  as  an  anti-arthritic  remedy,  and,  in  precipitated  form,  is 
still  prescribed  to  be  dusted  in  the  shoes,  whence  it  distinctly 
impregnates  the  system. 

The  best  of  the  sulphureous  waters  contain  saline  matters,  to 
which,  as  well  as  to  the  sulphides  and  free  sulphuretted  hydrogen, 
much  of  their  good  effects  are  due.  Harrogate  is  the  type  of  such 
waters. 

Aix-la-Chapelle  (Rhenish  Prussia). — Aix-la-Chapelle  has  a 
well-established  reputation,  but  is  now  more  frequented  for  the 
treatment  of  venereal  than  of  gouty  ailments.      This  notoriety 


446  WATER-DRINKING,  BATHS,  ETC. 

has,  for  no  sufficient  reason  as  regards  the  unquestionable  value 
of  the  waters,  debarred  of  late  years  many  gouty  patients  of  both 
sexes  from  having  recourse  to  their  advantages.  The  arrange- 
ments leave  nothing  to  be  desired.  Obstinate  chronic  arthritis, 
sciatica,  and  gouty  skin- disorders  are  well  treated  here  both  by 
bathing  and  water-drinking. 

Aix-les-Bains  (Savoy). — Aix-les-Bains  is  now  one  of  the  most 
frequented  thermal  stations  for  all  forms  of  gout,  and  its  waters 
are  of  great  service.  The  place  is  attractive  in  many  respects. 
For  obstinate  joint-affections,  skin-diseases,  sciatica,  and  in  atonic 
gouty  arthritis,  the  waters  are  of  great  value.  They  are  of  high 
thermality,  11 2°  to  114°  F.,  and  contain  calcium  and  mag- 
nesium carbonates  and  sulphates,  sodium  chloride,  hyposulphites, 
and  sulphuretted  hydrogen  gas.  The  system  of  bathing,  douch- 
ing, and  shampooing  is  carried  out  with  great  care  and  skill.  The 
course  is  often  better  preceded  by  one  of  water-drinking  at 
Carlsbad  or  Homburg,  especially  if  the  patient  be  plethoric.  The 
waters  of  Marlioz  and  Challes,  in  the  vicinity,  are  often  employed 
during  the  bath-treatment.  The  former  of  these  is  rich  in 
sodium  sulphide,  and  the  latter  contains  iodine  and  bromine  in 
large  amount,  together  with  sulphur. 

After  the  course,  patients  should  resort  to  some  alpine  station, 
as  Ragatz  or  Brides-les-Bains. 

Strathpeffer  (Ross-shire). — This  station  possesses  some  of 
the  most  powerful  sulphureous  waters  known,  and  is  available  for 
all  ailments  in  which  these  are  indicated.  The  accommodation 
and  arrangements  will  probably  be  improved  as  this  Spa  becomes 
more  frequented.  There  are  two  springs,  the  upper  one  contain- 
ing more  sulphuretted  hydrogen  than  any  other  British  mineral 
water.     Sodic  and  calcic  sulphates  are  the  chief  saline  ingredients. 

Moffat  (Dumfries-shire). — There  is  a  sulphur  spring  here  con- 
taining sodium  chloride.  It  is  of  great  value  in  some  forms  of 
irregular  gout. 

Luchon  (Pyrenees) — Bareges  (Hautes-Pyrenees). — Luchon  is 
available  for  such  cases  as  may  be  expected  to  derive  benefit  from 
thermal  sulphureous  waters,  and  the  same  applies  to  Bareges, 
where  the  springs  are  alkaline  as  well  as  saline  and  sulphureous, 
and  the  altitude  great,  4200  feet  above  the  sea-level. 

Harrogate  (Yorkshire). — This  station  supplies  sulphuretted 
waters  of  great  strength,  and  may  be  resorted  to  by  patients 
requiring  treatment  of  this  kind. 

Baden  (Switzerland,  near  Zurich). — At  this  station  is  a  thermal 
sulphureous  spring,  much  frequented,  and  of  value  in  chronic  and 


CHALYBEATE    WATERS.       SEA-BATHING.  447 

atonic  varieties  of  gout.  The  temperature  is  119°  F.  The  water 
is  used  chiefly  for  baths,  but  also  for  drinking.  There  are  present 
in  it  sodium  chloride  and  calcium  sulphate  and  carbonate. 

SCHINZNACH. — Not  far  from  Baden  is  Schinznach,  which  has 
stronger  but  athermal  sulphureous  waters,  containing  less  lime 
than  the  Baden  water,  and  a  moderate  amount  of  sodium  sulphate. 

7.  Bromo-Ioduretted  Waters. — Woodhall  (Lincolnshire). — The 
athermal  water  of  Woodhall  Spa  best  represents  this  class.  It 
has  proved  undoubtedly  beneficial  in  removing  the  results  of 
gouty  arthritis,  and  is  taken  internally,  and  employed  both  as 
baths  and  in  the  form  of  douches.  It  is  portable,  and  may  be 
taken  in  doses  of  four  or  six  to  thirty  ounces  daily  before  meals. 

Maelioz  (Savoy). — This  station  has  been  already  referred  to.  Its 
sulpho-sodic  and  bromo-ioduretted  waters  are  of  proved  utility. 

Cheltenham  (Gloucestershire). — Cheltenham  possesses  an  iodu- 
retted  and  sulphuretted  chalybeate,  also  ioduretted  saline  and 
magnesium  saline  waters. 

8.  Ferruginous  Waters. — The  number  of  chalybeate  springs  is 
legion.  They  are  not  generally  available  as  remedial  agents  in 
gouty  disorders,  and  such  waters  are  only  of  service  in  small 
quantities  in  cases  of  atonic  gout  with  anaemia.  The  tendency 
of  iron  to  injure  the  digestive  processes,  and  to  induce  retention 
of  uric  acid,  must  be  borne  in  mind  in  prescribing  a  course  of  iron 
waters.  In  spite  of  this,  many  patients  derive  benefit,  provided 
that  the  action  of  the  bowels  is  maintained.  Those  waters  of 
this  class  are  best  which  contain  saline  ingredients  in  addition. 

Spa  (Belgium),  Pyrmont  (Waldeck-Pyrmont),  St.  Moritz 
(Engadine),  Cheltenham,  Tunbridge  Wells  (Kent),  Schwal- 
bach  (Hessen-Nassau),  Booklet  (near  Kissingen),  and  Harro- 
gate are  amongst  the  best  known  and  frequented  chalybeate 
springs.  Recourse  may  be  had  to  some  of  these  stations  as  an 
after-cure,  following  a  course  at  other  Spas. 

As  a  general  rule,  however,  it  may  be  laid  down  that  sufficient 
iron  is  found  in  most  of  the  waters  in  repute  for  successful  treat- 
ment of  gout  and  gouty  states. 

St.  Nectaire  (Puy-de-D6me,  France). — The  waters  are  mixed 
alkaline  and  ferruginous,  bicarbonated,  both  cold  and  thermal, 
chiefly  resorted  to  by  French  patients. 

Orezza  (Corsica). — This  spring  furnishes  gaseous  chalybeate 
waters,  which  are  largely  exported. 

Sea-Bathing This  is  rarely  advisable,  and  of  doubtful  value 

after  the  age  of  fifty.     In  sthenic  gouty  cases  between  paroxysms, 


448  WATER-DRINKING,  BATHS,  ETC. 

and  in  young  subjects,  it  may  be  practised  with  prudence  and  in 
moderation,  if  found  to  agree.  For  older  persons  and  in  asthenic 
gout,  warm  sea-water  baths  and  douches  are  of  undoubted  value. 
In  cases  of  blended  struma  and  gout,  recourse  should  be  had  to 
the  seaside  for  some  weeks  each  summer.  The  waters  of  Salins- 
Moutiers,  already  referred  to,  constitute,  amidst  the  Alps  of 
Savoy,  "  une  veritable  mer  thermale,"  likely  to  be  of  great  value 
in  such  cases. 


Electricity  in  the  Treatment  of  the  Gouty. 

As  a  restorative  of  muscular,  nervous,  and  general  debility 
in  chronic  gout,  benefit  may  be  gained  from  electrical  baths. 
Amyotrophy,  due  to  arthritis,  is  powerfully  influenced  for  good 
by  voltaic  currents  applied  daily,  together  with  shampooing  of 
the  parts.  Neuralgia  and  neuritis  in  the  later  stages  sometimes 
yield  to  this  method,  and  post-zonal  neuralgia  may  be  thus 
treated  with  expectation  of  benefit. 

Friction  in  the  Treatment  of  Gout. 

The  adage  of  Sir  William  Temple,  to  the  effect  that  "  no 
man  need  have  the  gout  who  could  afford  a  slave  to  rub  him," 
is,  I  believe,  true.  As  this  diplomatist  was  our  Minister  at  the 
Hague  when  Boerhaave  was  a  youth,  it  is  not  unlikely  that  the 
latter  may  have  heard  of  the  recommendation,  and  so  been  led  to 
advise  friction  in  the  treatment  of  gout.1 

There  can  be  no  doubt  of  the  usefulness  of  regulated  friction 
in  promoting  a  more  active  interstitial  and  serous  circulation, 
and  in  dispersing  stases  of  peccant  material.  At  the  present 
time,  friction  is  much  in  vogue,  and  is  reduced  to  a  strict  thera- 
peutic method  by  trained  persons.  Like  all  other  plans  of  treat- 
ment, it  is  open  to  abuse,  and  too  much  has  been  claimed  for  it. 
It  has  a  place  in  the  management  of  chronic  gouty  cases  where 
crippling  is  threatened,  and  where  other  forms  of  exercise  are 
impracticable.  When  all  pain  has  passed  off  in  recently  affected 
joints,  friction  and  shampooing  may  be  practised  with  benefit. 
At  many  of  the  best-regulated  Spas  this  plan  is  adopted  both  in 
and  out  of  the  bath,  sometimes  alternating  with  the  latter.  It  is 
especially  useful  in  winter  months,  when  the  skin  is  inactive. 
Properly  conducted,  it  causes  slight  fatigue,  but  promotes  better 

1   "Exercitatio   inagno,  continuato,    equitationis  in   aere  puro,  turn  frictionihus, 
motibusque  partium  soepe  iteratis." — Aphorisms,  1275. 


TRAVELLING  IN  THE  TREATMENT  OF  GOUT.     449 

appetite  and  digestion.  It  must  not  be  overdone.  Friction  to 
the  extremities  is  very  useful  for  goutily  disposed  persons,  espe- 
cially before  any  debility  sets  in.  The  feet  should  be  daily 
washed  with  soap  and  water,  and  the  parts  well-rubbed  after- 
wards. The  socks  and  shoes  should  be  changed  twice  daily,  and 
in  some  cases  each  digit,  or  at  least  the  great-toe,  may  be  pro- 
vided with  a  distinct  encasement  by  "  thumb"  socks.  The  boots 
should  be  easy,  and  in  winter  provided  with  an  extra  cork-sole. 
Wet  boots  should  be  changed  as  soon  as  possible,  and  great 
comfort  is  attainable  by  having  many  pairs,  so  as  to  vary  the 
pressure  peculiar  to  each. 

Travelling"  in  the  Treatment  of  Gout. 

Much  of  the  benefit  derived  from  treatment  at  the  various 
Spas  depends  on  the  varied  influences  inseparable  from  travelling. 
Dry,  temperate,  hill  and  mountain  inland  air  commonly  suits  best ; 
but  exceptions  are  met  with,  some  patients  finding  benefit  from 
marine  influence.  Where  sea-voyages  are  well-borne  and  enjoyed, 
great  good  may  come  from  them.  The  unfavourable  elements 
in  these  arise  from  the  tendency  to  over-eat  and  to  take  insufficient 
exercise. 

If  the  winter  and  spring  seasons  are  spent  in  England,  some 
sheltered,  but  not  too  relaxing,  place  should  be  selected.  It  is 
easier  to  find  suitable  stations  beyond  these  islands.  The  Riviera 
presents  many  available  resorts.  Egypt  is  too  relaxing.  Algeria  is 
very  favourable  in  chronic  cases,  especially  with  renal  complications, 
and  so  is  Morocco.  For  patients  who  are  not  crippled  and  not 
too  feeble,  great  benefit  is  derivable  from  a  voyage  to  the  Cape 
of  Good  Hope  undertaken  in  the  early  months  of  the  year,  or 
from  one  to  India  begun  in  October.  The  cool  season  spent  in 
healthy  northern  parts  of  India  presents,  in  my  experience,  about 
the  best  climate  obtainable  anywhere.  Mexico  and  Southern 
California  also  afford  brilliancy  with  invigorating  air. 

It  must  always  be  borne  in  mind,  however,  that  no  climate  is 
by  itself  helpful  to  the  gouty,  unless  the  habits  of  life  are  suffi- 
ciently conformed  to  the  requirements  of  the  individual  patient, 
both  in  respect  of  exercise  and  diet.  The  effects  are  to  be  gauged 
by  the  condition  of  general  bodily  nutrition  and  nervous  vigour 
secured  in  each  instance.  If  the  traveller  is  not  happy  and  free 
to  enjoy  his  new  environments,  he  is  not  likely  to  derive 
benefit.  It  is  sometimes  very  difficult  to  induce  gouty  patients 
to  submit  to  the  varied  discomforts  of  travel.     They  are  prone  to 

2  f 


45 O  WATEE-DEIXKIXG,  BATHS,  ETC. 

prefer  tlieir  home-routine,  and  to  court  ease  and  wonted  pamper- 
ings.  It  is  often  well  to  break  in  on  this,  and  to  stir  up  dormant 
energy  by  the  jostle  and  variety  inseparable  from  any  form  of 
locomotion.  In  suitable  cases,  it  is  certain  that  much  benefit 
comes  from  occasional  travelling,  and  that  the  general  health  is 
so  far  restored  as  to  render  the  system  much  less  prone  to  suffer 
from  gouty  manifestations.  Habits  of  routine  and  perpetual 
search  for  comfort  too  commonly  induce  decay  of  power,  and  foster 
textural  degeneration  !New  scenes,  and  the  efforts  necessary  to 
reach  them,  often  avail  much  to  rouse  latent  energies  that  would 
otherwise  run  to  decay. 

Change  of  climate  sometimes  acts  in  a  remarkably  beneficial 
manner  on  patients  with  gouty  proclivity,  causing  paroxysmal 
phases  to  disappear,  and  many  forms  of  irregular  gout  to  sub- 
side. The  most  noteworthy  results  commonly  follow  resort  to 
inland  stations  on  the  Continent.  The  factors  which  favour 
these  desirable  effects  are  not  known  with  certainty.  I  am  dis- 
posed to  think  that  removal  from  sea-influences  counts  for  a  good 
deal.  The  quality  of  the  air,  as  favouring  the  action  of  the  skin, 
and  the  quality  of  the  water,  may  also  have  much  to  do  with 
the  matter.  The  dietary  is  often  lighter  in  quality,  less  strong, 
and  less  "  English,"  and  much  is,  doubtless,  due  to  altered  habits 
of  life  in  respect  of  mental  distraction,  exercise,  freedom  from 
cares  and  the  daily  "  grind  "  of  home-life.  The  more  brilliant  sky, 
the  greater  sun-power  and  general  brightness  also  avail  much,  in 
contrast  with  the  prevalent  dulness  and  moisture  of  the  British 
islands.  It  is  certain  that  obstinate  neuralgias,  sciatica,  and 
gouty  eczema  are  thus  very  favourably  influenced  by  prolonged 
residence  in  high  and  dry  stations  on  the  European  Continent. 


CHAPTER  XXIV. 

LIFE-ASSURANCE    IN    RELATION    TO    GOUT. 

A  careful  consideration  of  the  importance  of  gout  in  the  family 
and  life-histories  of  persons  offering  themselves  for  life-assurance, 
cannot  be  evaded  by  those  who  are  called  to  determine  the 
fitness  of  such  candidates.  Opinions  differ  widely  as  to  the 
measure  of  gravity  to  be  attached  to  gout  and  gouty  history  in 
these  cases.  It  is  obvious  that  no  hard  and  fast  line  of  action 
can  be  taken  in  respect  of  this,  yet  it  is  common  in  many 
Societies  to  affix  in  a  routine  fashion  an  extra  premium  amount- 
ing to  three  years  on  such  lives. 

Each  individual  demands  special  consideration  in  respect  of 
his  gouty  heritage  and  his  personal  gouty  manifestations. 

Such  of  the  latter  as  occur  in  early  life  must  be  taken  note 
of,  and  no  less  must  the  phases  of  incomplete  or  irregular  gout 
in  the  adult  be  duly  regarded. 

It  may  be  broadly  laid  down  that  attacks  of  frank,  regular 
gout,  occurring  after  forty  years  of  age,  are  altogether  less  grave 
than  those  which  break  out  before  thirty. 

In  the  latter  case,  there  is  probably  strongly  inherited  pro- 
clivity, and  a  consequent  enfeeblement  generally  of  the  consti- 
tution. Persons  thus  early  affected  are  apt  soon  to  become 
goutily  cachectic,  and  to  evince  signs  of  renal  or  cardiac  failure. 

Where  frank,  paroxysmal,  articular  gout  occurs  at  intervals 
later  in  life,  the  disorder  is  less  apt  to  lay  hold  of  the  constitution, 
and  to  lead  to  degenerative  visceral  and  vascular  changes.  The 
relative  ' '  weighting  "  of  these  two  classes  of  cases  should  surely 
be  very  different.  Some  persons  in  whom  gout  supervenes  early 
in  life  are  not  safe  for  assurance  on  any  terms ;  while  in  most  of 
them  the  existence  of  the  dyscrasia  in  this  form  demands  a  heavy 
addition.  The  points  demanding  attention  relate  especially  to 
the  condition  of  the  kidneys,  the  heart  and  vascular  system,  the 
liver,  and  the  digestive  system.     It  is  especially  necessary  not  to 


452  LIFE-ASSURANCE   IN   RELATION    TO    GOUT. 

be  misled  by  the  absence  of  articular  symptoms,  which  may  be 
marked  in  cases  which  are  otherwise  of  more  serious  import  in 
respect  of  the  condition  of  the  organs  just  mentioned.  Care  in 
auscultation  and  urinary  examination,  as  now  practised  by  medi- 
cal officers  to  life-assurance  societies,  commonly  avails  to  deter- 
mine the  gravity  in  any  case,  but  it  is  possible  that  the  fact  of 
associating  many  minor  lesions  with  gouty  taint  may  dispose  the 
observer  to  be  lenient  in  his  views,  and  unduly  considerate  in 
estimating  the  probabilities  of  life. 

The  association  of  alcoholic  excess  in  varying  degree  with  gouty 
habit  is  another  element  to  be  fitly  gauged  in  each  instance,  and 
in  both  sexes  ;  and  where  met  with  in  obvious  extent,  should  deter- 
mine against  acceptance  of  the  life. 

As  has  been  pointed  out,  some  of  the  worst  phases  of  gouty 
habit  may  supervene  in  perfectly  temperate  persons,  who  may 
nevertheless  claim  no  higher  consideration  for  assurance  purposes 
than  the  habitually  intemperate. 

Attention  to  the  specific  gravity  of  the  urine  in  the  absence  of 
albuminuria  will  aid,  with  other  clinical  features,  in  determining 
the  presence  or  absence  of  chronic  interstitial  nephritis,  which  is 
so  common  an  attendant  on,  or  rather  concomitant  of,  gout. 

The  state  of  the  arteries  in  respect  of  hardness  or  brittleness, 
together  with  plethoric  tendency  or  the  reverse,  will  avail  to 
guide  opinion  as  to  tendency  to  cerebral  or  other  hgeniorrhagic 
outbursts. 

No  case  of  gouty  cachexia  should  be  accepted  for  life-assurance. 
Sufferers  from  chronic  gout  should  be  declined,  if  signs  of  visceral 
and  vascular  degeneration  are  detected.  Cases  with  albuminuria, 
glycosuria,  hard  and  tortuous  arteries,  with  tense  pulse,  should 
be  rejected.  Emphysema,  with  bronchitic  tendency  and  cardiac 
dilatation,  are  also  inadmissible,  the  liability  to  suffocative  bron- 
chitis and  pneumonia  (almost  always  fatal  in  such  cases)  being 
borne  in  mind.  Any  degenerations  with  an  associated  obese 
condition  are  especially  bad.  Lean  and  wiry  subjects  admit 
of  better  prognostication  under  similar  circumstances.  The 
peculiar  vulnerability  of  the  goutily  cachectic  should  not  be 
forgotten. 

This  subject  has  received  careful  attention  from  Dr.  Symes 
Thompson,1  who  suggests  that  in  gouty  cases,  as  described  above, 
the  existence  of  any  of  these  degenerations  demands  more  serious 
attention  than  is  often  given  to  them  ;  and  he  has  expressed  the 
opinion  that  such  indications  require,  for  the  protection  of  the 
i  Med.  Times  and  Gazette,  vol.  i.,  1879,  p.  64. 


LIFE-ASSURANCE   IN   RELATION   TO   GOUT.  453 

societies,  not  less  than  an  addition  of  twenty  per  cent,  to  the 
premium  demanded.1 

The  medical  officer  must  do  his  duty  to  the  Society  and  to  the 
client,  but  it  not  infrequently  happens  that  the  latter  declines  to 
submit  to  the  increased  impost,  and  seeks  admission  to  some  other 
and  less  strict  assurance  company.  For  the  credit  of  all  concerned, 
it  were  well  that  some  measure  of  agreement  were  established  in 
respect  of  marking  the  true  significance  of  gout  and  gouty 
indications. 

It  sometimes  happens  that  clients  are  unfairly  judged  because 
too  much  importance  is  attached  to  minor  tokens  of  gouty  habit. 
Thus,  an  intermittent  pulse  may  cause  undue  anxiety.  It  may 
be  temporary  in  a  gouty  person,  or,  if  permanent,  of  no  real 
gravity.  Its  true  significance  is  to  be  gauged  by  other  signs, 
and  these  require  for  their  detection  skill  and  experience  of  such 
cases.  Again,  palpitation  may  cause  unnecessary  alarm,  and 
excite  fears  of  severe  organic  heart-disease  which  is  non-existent. 
Such  cases  should  be  referred  for  a  few  weeks  or  months,  and 
re-examined. 

1  Dr.  Alexander  Davidson,  of  Liverpool,  has  recently  adduced  evidence  which 
confirms  in  all  particulars  the  opinions  here  stated.  "  On  the  Medical  Selection  of 
Lives  for  Assurance."     Liverpool  Medico- Chirurgical  Journ.,  July  1889,  p.  243. 

In  the  Medical  Handbook  of  Life- Assurance,  by  Dr.  James  Edward  Pollock  and 
Mr.  Chisholm,  F.I. A.,  will  also  be  found  confirmatory  opinions.  (This  excellent 
work  was  issued  while  this  volume  was  passing  through  the  press.) 


CHAPTER  XXV. 

PROGNOSIS    IN    GOUT. 

In  framing  a  prognosis  in  any  disease,  regard  must  naturally  be 
had  to  all  the  factors  concerned  in  its  production,  and  no  less  to 
the  inherent  vital  power  and  resistance  manifested  by  the  person 
affected.  In  short,  the  prognosis  is  for  the  individual,  and  not  for 
gouty  patients  as  a  class.  The  same  holds  good  in  any  disease, 
and  similar  considerations  arise  in  discussing  the  prospects  in 
cases  of  phthisis,  heart-disease,  diabetes,  or  nephritis.  The  ques- 
tions are :  What  is  the  particular  significance  of  the  disorder  in 
the  individual,  and  what  degree  of  resisting  power  does  he  pos- 
sess against  its  influence  ?  In  gout,  a  special  question  arises 
with  respect  to  the  habits  of  life  as  to  diet,  exercise,  and  control 
of  the  appetites.  The  family  history  avails  much  to  aid  in  deter- 
mining prognosis.  Thus,  even  with  gouty  ancestry,  longevity  is 
a  powerful  and  favourable  factor.  The  prospects  in  the  case  of 
one  descended  from  a  robust  stock  are  vastly  better  than  those 
of  one  who  comes  of  a  frail  and  unresisting  one.  Regard  must 
be  had  to  the  influence  of  blended  diathesis,  as  struma,  and  of 
ancestral  intemperance.  Where  any  diathesis  is  marked,  malign 
results  may  be  distant  if  it  has  not  passed  on  to  become  a 
cachexia.  Where  gouty  paroxysms  have  proved  sthenic  and 
sharp,  and  long  intervals  have  occurred  between  the  attacks,  little 
if  any  curtailment  of  life  is  likely.  The  reason  for  this  opinion 
is  not  far  to  seek,  since  in  such  cases  there  is  usually  absence  of 
visceral  complications  and  degeneration  of  texture.  The  gout  is 
regular,  and  that  is  always  a  favourable  sign.  Where  visceral 
degeneration  prevails,  the  prognosis  is  unfavourable.  Rank  of 
life,  and  ability  to  ward  off  the  ill-effects  of  attacks,  count  for 
much  in  the  determination.  Amended  habits  and  self-control 
count  for  no  less.  If  gout  be  associated  with  struma,  and  the 
patient  live  over  forty  years,  the  prognosis  is  not  bad,  unless 


PROGNOSIS    IN   GOUT.  455 

strumous  tendency  predominates,  especially  if  care  be  taken,  and 
the  habits  are  prudent. 

In  persons  with  proclivity  to  vascular  disease  and  degeneration 
(vascular  diathesis),  the  prognosis  is  not  favourable  for  longevity, 
especially  if  the  patient  is  otherwise  of  feeble  constitution. 
Where  nervous  features  prevail,  as  more  often  seen  in  women, 
the  prognosis  is  not  unfavourable,  provided  the  nervous  element 
is  not  highly  predominant.  As  associated  with  obesity,  unless  in 
excess,  the  prognosis  of  gout  is  also  not  unfavourable. 

The  varieties  of  gout  were  affirmed  by  Laycock  to  be  dependent 
on  varieties  in  constitution.1  He  taught  that  all  the  diatheses  were 
liable  to  gouty  affections,  but  that  each  modified  its  course  and 
symptoms.  The  typical  English  form  he  regarded  as  the  san- 
guine; hence,  the  "sanguine  arthritic"  or  "John  Bull"  type, 
with  prevalence  of  sthenic  and  regular  paroxysms.  In  another 
type,  less  common  in  this  country,  the  "  bilious  arthritic,"  he 
was  of  opinion  that  the  disease  was  apt  to  be  asthenic,  and  to 
develop  at  an  earlier  age. 

In  the  category  of  the  ' '  nervous  arthritic  "  he  recognized  two 
forms  of  gouty  disease,  and  believed  that  it  might  complicate 
either  the  sanguine  or  the  bilious  type,  or  be  combined  with 
struma :  (a.)  JVetiro-arthritic  proper,  with  tendency  to  affection 
of  cerebro-spinal  axis,  with  its  nerves  and  their  investments ;  and 
(&.)  Neuro-vascidar  or  vaso-motor,  in  which  the  blood-vessels  of  the 
nerve-centres  were  involved  by  reason  of  alterations  in  the  vaso- 
motor nerves. 

1  These  views  were  taught  to  his  class  by  Laycock,  but  never  published  by  him. 
By  the  kindness  of  his  son,  Dr.  George  Laycock,  who  lent  me  for  perusal  some  of 
his  father's  manuscript  lectures,  I  am  enabled  to  record  them  here. 


INDEX. 


Abarticular  gout,  85 

Abdominal   aorta,    inordinate   pulsation 

of,  224 
Abortive  treatment  of  acute  gout,  348 
treatment  of   acute  gout ;    its  un- 

desirability,  348 
treatment    of     acute     gout,     Mr. 

Thomas  Pridgin  Teale  on,  348 
Acetabulum,  uratic  deposit  in,  69 
Acetanilide,  360 

Acetonuria  in  gouty  diabetes,  402 
Acids  induce  retention   of   uric  acid  in 

the  system,  43 
Acne,  317 

Aconite,  use  of,  in  tachycardia,  388 
Acquired  gout,  16,  128 
Action  of  colchicum  specific  in  gout,  32 
Acupuncture  in  treatment  of  sciatica,  384 
Acute  gout,  246 

gout,  albuminuria  in,  122 

gout,  dietetic  treatment  of,  363 

gout,  less  common  than  formerly, 

253 


119 

have 


died    of    the 


gout,  urine  in, 
Adam    alleged    to 

"gowte,"  128 
Adrenal  bodies,  96 
Advanced  life,  gout  in,  327 
.ZEstus  volaticus,  321 
African    continent,    gout    unknown    in 

native  races  of,  340 
Aix-la-Chapelle,  418,  445 
Aix-les-Bains,  388,  446 
Albumen  in  blood  of  the  gouty,  117 
Albuminuria  in  acute  gout,  122 

in  chronic  gout,  125 

Alcoholic  drinks,  suitability  of,  420 
Alexander  (of  Tralles)  on  hermodactyls, 

347. 
Algeria,  449 
Alkalescence    of    blood    diminished    in 

gout,  42,  116 
Alkalies  in  acute  gout,  360 
Alkaline  waters,  437 

and  saline  waters,  439 

Almonds,  430 

Alternation,  or  substitution,  in  neuroses, 

22 
Amelie-les-Bains,  441 
America,  United    States    of,    true    gout 

rare  in,  340 


Ammonium  phosphates,  362 
phosphates,  useful  in  gouty  glyco- 
suria, 362 
Amnesia  in  gouty  cachexia,  266 
Amyotrophy,  gouty,  313 
Anaemia  following  haemorrhages  rapidly 

recovered  from  in  the  gouty,  1 16 

in  chronic  gout,  265 

in  gout,  116 

in  saturnine  gout,  1 17 

Ancestral    history    of    arthritic   diseases 

difficult    to    procure    of    trustworthy 

character,  148 
Andral,  G.,   on   connexion  of  uric  acid 

with  gout,  6 
Aneurysm  rare  in  the  gouty,  109 
Angina  faucium,  294 

faucium,  gouty,  88 

pectoris,  219 

pectoris    (true),   treatment    during 

paroxysms,  390 
pectoris    (false),    treatment    during 

paroxysms,  390 

tonsillaris,  gouty  variety  of,  88 

Animal   food   causes    retention   of    uric 

acid,  42 
Ankylosis,  bony,  in  gout,  78 
•  false,  in  chronic  rheumatic  arthritis, 

78 

Anstie,  Dr.  F.  E.,  on    neuralgia   attri- 
buted to  gout,  230 

Antagonism  between  diabetes  and  gout, 

185 

between  gout  and  tubercle,  172 

Anthrax,  317 

treatment  of,  409 

Antifebrin,  360 

Antipyrin  in  hemicrania,  382 

Aorta,  changes  in,  108 

Aperients,  use  of,  in  chronic  gout,  374 

Aphasia,  287 

Apoplexia  arthritica,  286 

in  gout,  193 

in  gouty  diabetes,  193 

Arcachon,  388 

Aretaeus  on  tophi,  256 

Army,  gout  in  the,  335  _ 

Arsenic,  use  of,  in  chronic  gout,  373 

Arterial  pulsation,  treatment  of  inordi- 
nate, 388 

tension  in  gout,  300 


458 


INDEX. 


Arteries,  changes  in,  108 
Arterio-capillary  fibrosis,  1 06 
Arthralgia,  saturnine,  164 
Arthritic  diathesis  modified  by  struma, 

154 

habit  of  body,  17 

■ ■  habit  of  body  not  universal,  18 

obesity,  368 

— obesity,  treatment  of,  369 

ophthalmia,  94 

■ persons    sensitive     to    gonorrhoeal 

poison,  155 

phthisis,  170 

pneumonia,  86 

tubercular  cachexia,  170 

Arthritis  deformans  uratica,  260 

suppurative,  82 

Arthritism,  one-sided  manifestations  of, 

sometimes   manifested  after  acute 

illness,  209 
Arthropathia  des  hdmiplegiques,  236 
Arthropathies  of  spinal  origin,  25 
Arthropathy,  plumbic,  163 
Artichokes,  429 
Articular    cartilage,    appearances  of,   in 

gout,  58 

gout  in  cases  of  glycosuria,  194 

gout,  morbid  anatomy  of,  56 

Artisans,  gout  in,  337 

Arytenoid  cartilages,  uratic  deposit  in, 

85 

Asparagus,  395,  429 

Asthma,  gout  in  relation  to,  217 

hay,  219 

treatment  of,  387 

Atavism,  131 

■ in  gout,  128 

Atropine  as  a  local  application  for  acute 
gout,  350 

Auditory  meatus,  gouty  disorders  of,  96 

Auricle,  hardness  of,  in  the  gouty,  90 

Auricular  tophi  in  case  of  haemophilia, 
82 

tophi  rare  in  women,  90 

tophi,  statistics  as  to,  90 

Australian  wines,  422 

Author's  views  respecting  chronic  rheum- 
atic arthritis,  1 55 

Axial  distortion  of  digits,  causes  of,  in 
gout,  79 

Bacilli  of  tubercle,  alleged  influence  of 
uric  acid  on,  171 

Baden,  446 

Baden-Baden,  407,  441 

Bagneres  de  Bigorre,  442 

Bagshot,  388 

Balanitis,  treatment  of,  405 

Balfour,  Dr.  G.  W..  on  cardiac  palpita- 
tion in  the  gouty,  298 

Ball,  Professor,  on  gout  in  the  stomach, 
290 

on  spinal  arthropathy,  24 

on       tophus-formation       following 

gouty  pain,  210 


Bandaging  for  gouty  joints,  363 
Barclay,    Dr.    A.    W.,    his    criticism    of 

Garrod's  views,  8 
on  the  use  of  salicylates   in   gout, 

356 
Barium,  418,  442 

"  Barometric,"  arthritically  disposed  per- 
sons are,  341 
Bath,  404,  407,  416,  435 
Baumes,  M.,  on  progeny  of   gouty  and 

tubercular  parents,  175 
Beans,  395,  429 
Beau,  M.,  on  transverse  depressions  on 

nails,  93,  252 
Beer,  German,  less  gout-provoking  than 

British  beer,  424 
Beetroot,  429 
Begbie,  Dr.  James,  on  gouty  Heberden's 

nodes,  71 
on   gouty  disorders  of  the   uterus, 

"3 

Dr.  J.  Warburton,  on  gout  in  Edin- 
burgh, 158 
Belfast,    absence    of    saturnine    gout  in, 

J59 
Belly    when    hard    indicates    purgation, 

351 
Benzoates,  use  of,  in  gout,  372 
Berthollet  bath,  436 
Bilateral  neuralgia  in  diabetes  mellitus, 

229 
Biliary  calculi,  ill,  394 

colic,  treatment  of,  394 

■ ■  colic,    somewhat    rare     after    fifty 

years  of  age,  ill 

and  renal  calculi  often  co- exist,  III 

Bird,  Dr.  G.,  on  the  use  of  benzoates,  372 

Bitter  acidulated  waters,  441 

Bladder,  retrocedence  of  gout  to  the,  293 

Bladder,  urinary,  112 

Blisters  in  acute  gout,  350 

Blood  cannot  be  rendered  acid,  42 

corpuscles  in  gout,  1 16 

plasma  in  gout,  116      ' 

state  insufficient  to  explain  pheno- 
mena of  gout,  44 
Bocker    on   retention    of  phosphates    in 

the  system  in  gout,  12 1 
Booklet,  447 
Boerhaave  on  the  employment  of  friction 

in  gout,  448 

on  harmfulness  of  asparagus,  429 

Boils,  317 

in  cases  of  glycosuria,  192 

Bone,  acute  necrosis  of,  316 

urates  in,  70 

Bones,  diminution  of  earthy  phosphates 

and  carbonates  in  those  of  the  gouty, 

I24 
of  gouty,  fatty  condition  of,  70 

often  large  in  the  gouty,  40 

Boots,  influence  of,  in  causing  deflections 

of  toes,  80 

tight,  as  excitant  of  gout,  250 

wearing  of,  as  a  cause  of  distortion 

of  toes,  80 


INDEX. 


459 


Bordeaux  wine,  genuine,  the  best  for  the 
gouty,  424 

Bouloumie",  M.,  on  treatment  by  salicy- 
lates, 358 

Bournemouth,  388 

Bowl  by,  Mr.  N.,  his  views  on  uratic 
encrustation  of  cartilage,  64 

Braemar,  384 

Brandy,  425 

Brides-les-Bains,  439,  441 

British  Isles,  more  gout  in  the,  than  else- 
where, 338 

Brodie,  Sir  B.,  on  rheumatic  gout,  144 

Bromide  of  caffeine,  382 

of  lithium,  380 

Bronchitis,  gouty,  85 

treatment  of,  386 

Brunton,  Dr.  T.  L.,  on  action  of  colchi- 
cum,  355 

on  gouty  glycosuria,  182 

on  lead  as  inducing  gout,  164 

"  Buck  "  teeth,  93 

Budd,  Dr.  G.,  on  gastric  gout,  293 

Dr.  W.,   case    of   cancer  in  gouty 

man,  176 

Bunion,  251 

Burgundy,    wines    of,    gout- provoking, 

421 
Bursal  cysts  ("  crab's-eyes  "),  83 
Bursitis,  suppurative,  82 
Burton,  Dr.  H.,  discovery  of  blue  line  on 

gums  in  lead-impregnation,  161 
Burtonian  blue  line  sometimes  absent  in 

lead-impregnation,  161 
Butcher's  meat,  36; 
Butlin,    Mr.    H.   T.,  on   cancer  in   the 

gouty,  176 

on  lingual  leucoplakia,  87 

Buxton,  404,  407,  435 

waters,    their    value    in    saturnine 

gout,  436 

Buzzard,  Dr.  T.,  on  gastric  crises  in  tabes 

dorsalis,  24 
on  gout  of  lymph-spaces,  98 

Cachexia,  gouty,  264 

Calculi,  renal,  remarkable  case  of,  in  a 
gouty  man,  302 

Calculous  cystitis,  112 

disease  prevented  by  salt,  36 

California,  South,  449 

Californian  wines,  424 

Cameron,  Dr.  J.,  on  absence  of  satur- 
nine gout  in  Liverpool,  160 

Campbell,  Dr.  H.,  on  the  power  of  acquir- 
ing disease,  129 

on  inheritance  of  acquisition,  129 

Canada,  gout  little  prevalent  in,  340 

Cancer,  alleged  frequency  of,  in  the 
gouty,  176 

and  gout,  175 

in  the  gouty  apt  to  be  painful,  176 

in  the  gouty,  its  special  painfulness, 

27 

of   gall-bladder  in   gouty   women, 

112 


Cantani,  on  disintegration  of  gelatinous 

structures  into  uric  acid,  64 
Capacity  for  intellectual   labour  during 

gouty  fits,  253 
Capillaries,  changes  in.  108 
Capillary  circulation  in  the  gouty  often 

feeble,  40 
Capsular  hepatitis,  no 
Capvern,  443 
Carbuncle,  317 
Cardiac  degenerations  in  gout,  106 

failure   in   chronic  saccharine  dia- 
betes, 190 

gout,  284 

neuroses,  298 

valves,  urates  in,  85 

■ ■  walls,  changes  in,  in  gout,  107 

Cardio-vascular  changes  in  gout,  105 

neuroses,  219 

Carlsbad,  369,  395,  407,  440 
Carter,  Dr.  W.,  on  ursemic  asthma,  219 
Cartilage,  articular,  nutrition  of,  61 
cells  in  relation  to  uratic  deposition, 

63 

cells  not  foci  of  uratic  deposit,  67 

diarthrodial,     in     health     and     at 

various  ages,  61 

of  ears,  hard  in  the  gouty,  91 

erosion  of,  more  frequent  in  gouty 

than  in  other  persons,  68 

sites  of  uratic  deposit  in,  65 

ulceration    of,    a    manifestation   of 

gouty  arthritis,  145 
Castor  oil  useful  in   warding  off  attacks 

of  gout,  417 
Cataract  rare  in  gouty  diabetes,  403 
Catarrhal  pneumonia,  86 
Cazalis,  H.,  on  hemi-rhumatisme,  49 
Celery,  429 
Cerebral  gout,  285,  287 

meninges,  urates  in,  98 

haemorrhage,  gout  and,  109 

Cerebro-spinal   fluid,    sodium   urate    in, 

98 
Chalky  soils   not   unfavourable    for   the 

gouty,  342 
Champagne  gout-provoking,  421 
Charcot,  Prof.  J.  M.,  criticism  of  Garrod's 

views  by,  8 
on  relation  between  gout  and  dia- 
betes, 181 

on  the  basic  arthritic  diathesis,  1 7 

on  saturnine  gout  in  Paris,  160 

"Charcot's  disease,"  149 

Chatel-Guydn,  444 

Chastity,  368 

Cheltenham,  444,  447 

Chestnuts,  430 

Chilblain-type,     disorders     of,     in     the 

gouty,  40 
Chlorosis    in   girls    of   gouty  parentage, 

418 

urichfemia  in,  116 

Chorea  and  gout,  216 

Christison,  Sir  R. ,  on  gout  in  women, 
323 


460 


INDEX. 


Chronic  cystitis,  113 

gout,  254 

■ ■  gout,  anaemia  in,  265 

gout,  polyuria  in,  125 

gout,  urichgemia  present  in  inter- 
paroxysmal  periods  of,  115 

■  rheumatic  arthritis,   Mr,  A.   Lane 

on  cause  of,  79 

rheumatic  arthritis  and  gout  may 

blend,  60 

rheumatic  arthritis  often  miscalled 

"rheumatic  gout,"  16 
rheumatic  arthritis,  opinions  as  to 

pathology  of,  140 
rheumatic  arthritis,  tachycardia  in, 

222 

Cider     commonly    unsuitable     for    the 

gouty,  423 
Cider-drinking   and    saturnism,    Sir    G. 

Baker  on,  156 
Circulus  articuli  vasculosus,  63 
Circum-articular  abscess  opening  into  a 

gouty  joint,  83 
Cirrhosis  of  liver,  hypertrophic,  ill 
"  Claret,"  so-called,  422 
Clark,  Sir  A.,  on  cases  of  cerebral  gout, 

288 
Classification  of  gout,  Durand-Fardel's, 

211 

of  gout,  Lecorche's,  211 

Clergy,  incidence  of  gout  upon,  333 

Clifton,  388,  435 

Clinical  experience  the  ultimate  appeal 

as  to  the  value  of  a  drug,  373 
■  study  of  gout,  method  of  prosecut- 
ing, 241 

varieties  of  gout,  Chapter  xii.,  243 

Coalescence    of    gout   and   rheumatism, 

147 

■ of  gout  and  struma,  1 71 

Cocaine  as  a  local  application,  350 

Coccyodynia,  272 

Coccyx,  pain  in,  272 

Cocoa,  430 

Coffee,  430 

Colchicina,  352 

hypodermic  use  of,  353 

Colchicum  a  nervine  drug,  32 

Dr.  Robertson  on  the  employment 

of.  335 

■ green  stools  after  employment  of, 

352. 

■  in  treatment  of  acute  gout,  35 1 

physiological  action  of,  32 

relieves  painfulness  of  gout,  32 

theories  as  to  action  of,  353 

autumnale,  347 

variegatum,  347 

Colic,  89 

arthritic,  formerly  confounded  with 

lead-colic,  291 
Colica  arthritica,  275 
Collodium  flexile,  350 
Colonists,  why  free  from  gout,  341 
Coma,  286 
in  gouty  diabetes,  403 


Commingling  of  gout,  134 
Compotes,  German,  unwholesome,  440 
Compound  tincture  of  colchicum,  352 
Conditions   favouring  uratic  deposition, 

57 
Conjunctivitis,  95 

Conjunctival  haemorrhage,  274 

Connective  tissue,  uratic  deposit  in,  79 

Constitution  of  the  seasons,  344 

Continental  Spas,  attractions  of,  434 

Contrexe"ville,  395,  404,  416,  438 

Cooking,  suitable  methods  of,  367 

Copland,  Dr.  J.,  on  gout  as  a  predis- 

ponent  cause  of  epilepsy,  216 
on  hysteria  in  daughters  of  gouty 

parents,  233 
Cornea,  uric  acid  highly  injurious  to,  70 
Cornil    and  Ranvier   on    marginal    out- 
growths in  arthritis,  75 
and    Ranvier   on    primary  site    of 

uratic  deposit  in  cartilage,  14 
and  Ranvier,  on  site  of  renal  uratic 

deposition,  103 
Cornillon,  M.,  on  gouty  amyotrophy,  313 
Corpus  cavernosum,  induration  of  sheath 

of,  112 
cavernosum,  thrombosis  of  veins  in 

the,  112 
Corrigan's  thermic  hammer,  383,  384 
"  Crab's-eye  "  cysts,  81 

cysts  over  phalangeal  joints,  83 

nodules,  nature  of,  271 

Cramp  in  muscles,  273,  281 

treatment  of,  385 

Cramps  in  legs  in  gout,  28 

Cream,  395 

Crichton-Browne,    Sir  J.,  on   gout  and 

insanity,  214 

on  melancholia  attonita,  214 

Critchett,  Mr.,  case  of  suppuration  of  the 

eyeball  in  a  gouty  man,  313 
Cruciferaa,  429 
Cruveilhier,  views  of,  6,  8 
Cullen,  his  doctrine  as  to  nervous  origin 

of  gout,  5 

on  curability  of  gout,  345 

on  physiognomy  of  the  gouty,  89 

Cuming,  Prof.  J.,  on  absence  of  saturnine 

gout  in  Belfast,  159 
Curability  of  gout  questioned,  345 

of  gout,  Cullen  on,  345 

of  gout,  Trousseau  on,  345 

Cutaneous  gravel,  92 

system,  89 

system  in  the  gouty,  89 

Cyragra,  4 
Cystitis,  112 

chronic,  1 13 

metastatic,  1 12,  276 

treatment  of,  406 

Da  Costa,  Dr.,  on  cardio-vascular 
changes  associated  with  chronic  neph- 
ritis, 263 

on  nervous  symptoms  of  lithsemia, 

340 


INDEX.  461 


Dalby,  Sir  W.,  on   gouty   conditions   of 

auditory  meatus,  97 
on    multiple   hyperostosis   of    bony 

auditory  meatus,  97 
Daughters  of  gouty  men  often  suffer  from 

chronic  rheumatic  arthritis,  153 
Davidson,  Dr.  A.,  on  absence  of  saturnine 

gout  in  Liverpool,  160 

■ on  gout  and  life-assurance,  453 

Davy,  Mr.   R.,   on    cider  in    relation   to 

gout  in  Devonshire,  423 
Dax,  388,  434,  439 
"Dead  fingers,"  277 
Deafness,  97 
Debout  d'Estre'es,  Dr.,  on  gouty  orchitis, 

"3 

on  intravesical    rupture  of   calculi, 

302 

Definition  of  gout,  1 

Definitions  of  disease,  Paget  on,  I 

Deflections  of  digits  in  gout  and  rheu- 
matism, 79 

Delirium  tremens  follows  the  law  of 
dietetic  ailments  as  to  frequency  at 
certain  seasons,  343 

supervenes    in    men    of     superior 

ability,  32 

Dendritic  lipoma  in   synovial  fringes  of 

gouty  joints,  78 
Deposits  of  sodium  urate   doubly  refract 

light,  34 
Depressing  effects  of  alkaline  treatment, 

362 
Dermatitis  exfoliativa,  318 
Desquamation  of  cuticle  after  gout,  249 
D'Estre'es,  Dr.  Debout,   on    intravesical 

rupture  of  calculi,  302 
Determinants  of  gouty  paroxysms,  244 

of  seizures  in  the  gouty,  28 

Devonshire  colic,  Sir  G.  Baker  on,  156 
Diabetes  alternans  in  the  gouty,  30 

cases  illustrating  gouty,  398 

cases  illustrating  grave  form  of,  in 

sons  of  gouty  men,  400 

intermitting,  180 

in  relation  to  gout,  30 

rare    in    association   with    chronic 

rheumatic  arthritis,  154 

saccharine,  178 

unity  of,  1 79 

Diagnosis,  physiognomical  method  of,  17 
Diarrhoea,  89 

in  gouty  cachexia,  266 

Diaphragmatic  gout,  221 

Diarthrodial  cartilage  in  health  and  at 

various  ages,  61 
Diathetic  predisposition  in    the   goutily 

disposed,  18 
Dickinson,   Dr.   W.  H.,   on  ansemia  in 

granulative  nephritis,  117 

on    glycosuria    of    hepatic    origin, 

182 

■ on  interstitial  nephritis  in  connexion 

with  gout,  100 

on  tongue  in  gout,  87 

Diet,  risks  of  change  of,  428 


Digital  distortions  not  always  present  in 

the  gouty,  80 
Digitalis,  389 
Digits,  changes  in,  often  similar  in  gouty 

and  rheumatic  disease,  65 

distorted  in  gout,  79 

varieties  of  distortion  of,  81,  82 

Dinner-parties,  366 
Diphtheria  in  the  gouty,  208 
Disordera  simulating  acute  gout,  316 
Distortion  of  digits,  varieties  of,  81 
of    phalanges,    various    forms    of, 

81 
Loclrinaire,  the,  in  medicine,  a  danger- 
ous person,  430 
Donovan's  solution,  419 
Drummond,  Dr.  D.,  on  absence  of  gout 

in  Newcastle-on-Tyne,  159 
Dublin,  plumbic  arthritis  in,  159 
Duncan,  Dr.  J.  M. ,  on  gouty  disorders 

of  womb  and  ovaries,  1 1 3 
Dunstan,    Prof.,    on   the    bitter  henno- 

dactyls,  347 
Dupuytren's  contraction  of  palmar  fascia, 

Dura  mater  of  spine,  urates  in,  98 
Durand-Fardel,  his  classification  of  gout, 

211 
Dysmenorrhea,  277 

congestive,  treatment  of,  407 

in  gouty  women,  113 

Dysphagia  in  gout,  30 

Ear,  condition  of  auditory  meatus  in 
the  gouty,  96 

gouty  affections  of,  96 

tophi  in,  90 

Early  life,  gout  in,  326 

Ears,  induration  of,  in  the  gouty,  90 

East  winds  noxious  to  the  gouty,  342 

Ebstein,  Prof.  W.,  on  arthritic  obesity, 
368 

on  crystallization  of  urates  in  nor- 
mal tissues,  65 

on    employment   of    salicylates    in 

gout,  359 

on  necrosis  in  cartilage  of  the  gouty, 

67 
on  production  of  uric  acid  in  muscles 

and  medullse  of  bones,  40 
remarks    on   uratic   infiltration    of 

tissues,  65 

views    on    intimate    pathology   of 

gout,  13 

Eburnation  of  bone  extremely  rare  in 
gout,  77 

Ecchondroses  in  chronic  rheumatic  ar- 
thritis, 73 

Ecchondrosis,  histology  of  rheumatic,  77 

Eczema,  318 

metastasis  of,  319 

■ ■  treatment  of,  411 

uric  acid  in  contents  of  vesicles  of 

gouty,  93 

Edinburgh,  immunity  from  saturnine 
gout  in,  158 


462  INDEX. 

Egypt,  449 

Ehrlich,   Prof.,  notes  on  cases  of  lead- 
impregnation,  167 
Elective  affinity  for  joints  in  gout,  31 
Electricity  in  the  treatment  of  the  gouty, 

Emphysema  of  lungs  in  the  gouty,  85,  86 

pulmonary,  in  chronic  gout,  264 

Embolic  pneumonia,  86 

Ems,  407,  412,  442 

Enanthem,  an,  319 

Endarteritis  obliterans,  1 05 

Endocarditis,  108 

Ensiform  cartilage,  pain  in,  272 

Enteralgia,  89 

Enterodynia,  291 

Epilepsy  sometimes  removed  by  onset 
of  gout,  30 

treatment  of,  381 

■  and  gout,  215 

Episcleritis,  95,  274 

Epistaxis,  272 

Epsom  water,  441 

Equitation,  value  of,  365 

Erysipelas,  209 

daughters  of  gouty  men  liable  to, 

209 

following  surgical  interference  with 

tophi,  376 

Euonymin,  417 

Euphoria,  244 

common  as  gouty  antecedent,  26 

Evian-les-Bains,  437,  439 

Exanthemata,  209 

Exercise,  365 

Exophthalmic  goitre,  222 

Exostoses,  gouty,  73 

Exostosis  a  gouty,  and  ecchondrosis  a 
rheumatic,  lesion,  76 

histology  of  gouty,  75 

Explosive  features  of  gout,  how  ex- 
plained, 47 

Explosiveness,  a  feature  of  the  neuroses, 
26 

Eye,  diseases  of  the,  in  the  gouty,  95 

gouty  disorders  of,  94 

Eyeball,  destructive  inflammation  of,  96 


Facial  palsy,  384 

Earinaceous  food  in  excess,  bad,  429 

Farmers,  incidence  of  gout  upon,  336 

Fat,  urates  in,  78 

Fatty  bones  in  gout,  70 

. condition  of  bones  in  the  gouty,  70 

degeneration  of  the  liver,  no 

Femur,  uratic  deposit  on  head  of,  69 
Fenwick,  Dr.  S.,  on  deficiency  of  potas- 
sium sulpho-cyanide  in  lead-impregna- 
tion, 1 01 
Ferruginous  waters,  447 
Fibrin  in  blood  of  the  gouty,  1 1 7 
Fibro-cartilage,  uratic  deposit  in,  79 
Fingers,  cause  of  distortion  of,  79 
Flanged  joints,  72 

Flatulency   in   metastatic   gastric   gout, 
377 


Fleeting  albuminuria  in  acute  gout,  123 
'•'Flying"  blisters,  351 

gout,  255,  284 

Fomentations,  350 

Food-diathesis,  gout  considered  as  a,  41 

Fools  rarely  gouty,  32 

Foot-addle,    earliest    Saxon     name    for 

gout,  4 
Foot,  Dr.  A.  W.,  on  plumbic  arthritis, 

159 

Forbes,  Mr.  M.,  on  connection  of  j  uric 
acid  with  gout,  6 

Foster,  Sir  B.  W.,  on  absence  of  satur- 
nine gout  in  Birmingham,  159  f 

Fothergill,  Dr.  M.,  on  glycosuria,  188 

"  Four-ale  "  a  gout-inducing  beverage, 
424 

French  chalk,  350 

Frequency  of  gout  in  England,  how 
explained,  23 

Frerichs,  Prof.  F.  T.,  on  lead-impregna- 
tion in  Berlin,  167 

Friction,  375 

in  the  treatment  of  gout,  448 

Friedrichshall  water,  370,  441 

Fruit  bad  for  the  gouty,  428 

and  wine  taken   together  noxious 

to  the  gouty,  430 

Fugitive  gouty  inflammation,  320 

Fuller,  Dr.  H.  W.,  on  rheumatic  gout, 

143.  H4 
reference  to  Stanley's  specimens  of 

gouty  joints,  59 
Furoncles  uriques,  1 92 
Furring  of  tongue  in  gout,  87 
Furunculi,  317 
treatment  of,  409 

Gairdnkr,  Professor,  on  connection  be- 
tween gout  and  angina  pectoris,  220 

gout  as  met  with  in  Glasgow,  158 

Dr.    W.,    discharge   of    phosphates 

after  gouty  paroxysms,  122 

objections  to  Garrod's  views,  8 

Gall-bladder,  cancer  of,  in  gouty  women, 

112 

stones,  ailments  allied  to  condition 

inducing,  in 

stones,  habits  of  life  leading  to  for- 
mation of,  III 

stones,  not  common  in  hot  climates, 

112 

stones,  seldom  found  associated  with 

hepatic  cirrhosis,  1 12 

Gangrene,  83,  31 1 

following  surgical  interference  with 

tophi,  376 

in  cases  of  gouty  diabetes,  192 

without  glycosuria,  83 

Garrod,  his  demonstration  of  uric  acid  as 
peccant  matter  of  gout,  6 

his  "  thread-tests  "  for  urichsemia, 

"5 

on  excretion  of  urea  in  gout,  39 

on   gout    in   relation  to  diabetes, 

181 


INDEX.  463 


Garrod  on  saturnine  gont,  156 

his  theory  of  the  relation  between 

uric  acid  and  gout,  7 
Gastein,  435,  437 
Gastrectasia,  291 
Gastric  gout,  treatment  of,  377 

symptoms  in  gout,  89 

Gastritis,  gouty,  89 
Gastro-enteric  gout,  289 

enteritis,  292 

Gelatinous  food,  objectionable,  363 
Genito-crural  herpes,  230 
Geographical  distribution  of,  and  influ- 
ence of  climate,  soil,  water,  and  seasons 

on  gout,  Chapter  xx.,  338 
Gicht,  misuse  of  term  in  Germany,  4 
Giesshilbel  water,  416 
Gland,  prostate,  gout  in,  113 
Glasgow,   saturnine  gout  not  met  with 

in,  158 
Glaucoma,  94,  95 
Gleet,  intractable  forms  of,  in  the  gouty, 

I78 
Glucose  in  urine  in  acute  gout,  123 

normally  present  in  urine,  185 

Glycerine,  428 

Glycocine,  whence  derived,  34 

Glycosuria,  178 

a  form  of  visceral  gout,  189 

common  in  the  gouty,  154 

in  young  women,  193 

onset  of,  sometimes  relieves  gouty 

symptoms,  127 
use   of   ammonium  phosphate    in, 

362 

and  acute  gout,  401 

and    chronic    rheumatic  arthritis, 

187 

and  gouty  diabetes,  treatment,  394 

Glycotaxic  centre  in  medulla  oblongata, 

31 

Gnashing  of  teeth  in  gouty,  27 

Gonorrhoea  and  sclerotitis,  177 

Gonorrhoeal  rheumatism,  316 

rheumatism,    special    tendency   to, 

in  the  gouty,  177 
Gout,  abarticular,  85 

a  diathetic  neurosis,  22 

affecting  the  ear,  96 

■  affecting  the  heart,  297 

affecting  the  tarsus,  261 

a  food-diathesis,  41 

a  neuro-humoral  disease,  20 

ansemia  in  relation  to,  116 

as  a  tropho-neurosis,  18 

as  yet  little  known  in  United  States 

of  America,  37 

a  so-called  Protean  malady,  16 

at  an  early  age  significant  of  strong 

heredity  of  the  disease,  264 

atavism  in,  128 

attacks  large  and  small  joints,  58 

cramps  in  legs  in,  28 

definition  of,  Chapter  i.,  1 

diabetes  in  connexion  with,  30 

diaphragmatic,  221 


Gout,  digestic  incapacity  for  certain  kinds 
of  food  in,  25 

disorders  of  the  eye  in,  94 

dysphagia  in,  30 

euphoria  in,  26 

explosive  features  of,  how  explained, 

47 
first  outbreak  after  ninety  years  of 

age,  25 
follows  the  laws  of  nervous  diseases 

as  to  frequency  and  intensity  at  certain 

seasons,  343 

frequent  in  the  third  decade,  25 

■  gangrene  in,  83 

hereditary,  128 

■ ■  heredity  in,  130 

heredity  of,  16 

haematology  of,  115 

hyperinosis  in,  117 

hypochondriasis  in,  29 

in  advanced  life,  327 

incomplete,  267 

-inducing  habits,  129 

influences  of  climate  on,  29 

in  infancy,  326 

in  overt  form   may  appear  late  in 

life,  268 

in  paralysed  limbs,  234 

in  relation  to  angina  pectoris,  219 

in  relation  to  asthma,  217 

in  relation  to  diabetes  and  glyco- 
suria, 178 

in  relation  to  haemophilia,  201 

in  relation  to  neuralgia,  228 

in  relation  to  purpura,  199 

in  relation    to   the  various    classes 

and  avocations  of  society,  332 

■  in  relation  to  various  neuroses,  213 

insomnia  in,  28 

instability  of  nervous  system  in,  26 

in  testis,  113 

in  women  in  early  and  in  advanced 

life,  Chapter  xvii.,  323 

irregular,  267 

lead-impregnation  in,  30 

minor   signs   of,    often    overlooked 

and  unappreciated,  25 

haemorrhages  in,  109 

often    transmitted    by   the    female 

line,  though  more  manifested  in  males, 

26 
■ ■  on   conditions   allied   to,  in  lower 

animals,  Chapter  viii.,  132 

osteoma  of  tibia  in,  78 

outbreaks    of    common,    in    early 

morning,  26 

pathological  doctrines  concerning,  5 

• periodic  element  in,  26 

physical  theory  of,  49 

pleurisy  in,  86 

"poor  man's,"  3 

premonitory  signs  of,  243 

prostatic,  113 

-provoking    qualities   of    alcoholic 

drinks,  425 
rare  in  Dublin,  159 


464 


INDEX. 


Gout  in  hip-joint,  69 

rarely  affects  the  shoulder-joint,  70 

Saxon  name  for,  4 

somnambulism  in,  27 

sweating  as  a  means  of  relief  in,  50 

symptoms  of  imperfect,  35 

ulceration  of  cartilages  in,  68 

urology  of,  Chapter  vi.,  1 18 

vascular  throbbings  in,  30 

vertigo  in,  30 

visceral,  85 

why  not  induced  in  United  States 

of  America,  340 

without  digital  distortions,  80 

and  cancer,  175 

and  cerebral  haemorrhage,  109 

and  chorea,  216 

and  chronic  rheumatic  arthritis  may 

blend,  60 

and  diphtheria,  208 

and  epilepsy,  215 

and    gravel,    apt    to    alternate    in 

succeeding  generations,  37 

and  hsematinuria,  201 

■  and  insanity  related,  1 54 

and  lardaceous  disease,  1 06 

and  leuchasmia,  198 

and  melancholia,  214 

and  obesity,  195 

■  and  osteitis  deformans,  207 

and  oxaluria,  relationship  between, 

196 

and  pyajmic  arthritis,  2 1 1 

and  rheumatism,  the  relation  be- 
tween, 134 

and   saturnism,    relation   between, 

mostly  noted   in    London   and  Paris, 

157 

and  struma,  170 

and  struma,  treatment  for,  417 

and  syphilis,  176 

and  syphilis,  treatment  for,  418 

and  traumatism,  205 

and  tuberculosis,  170 

and  typhus  fever,  208 

Gouty  affections  of  the  eye, treatment,  408 

affections  of  the  liver,  393 

amyotrophy,  313 

■  angina  faucium,  88 

arthritis  without  uratic  deposit,  252 

bronchitis,  85 

■  cachexia,  264 

cachexia  and  gout  in  elderly  per- 
sons, treatment,  413 

characters  of  hair  in  the,  91 

characters  of  nails  in  the,  93 

characters  of  the  teeth  in  the,  93 

deposits    and    symptoms,    relation 

between,  51 

diabetes,  cases  illustrating,  398 

diabetes,  treatment  of,  402 

diathesis    varied  by   intermixture, 

128 

diathesis  widely  spread,  128 

disorders  of  uterus,  113 

disorders,  Dr.  J.  Begbie  on,  113 


Gouty  disorders  of  uterus  and  ovaries, 
morbid  anatomy  of,  114 

dyspepsia,  303 

encephalopathy,  286 

exostoses,  73 

glycosuria,  126 

glycosuria,  pathogeny  of,  188 

idiosyncrasy,  239 

interstitial  nephritis,  treatment  of, 

403  . 

kidneys,  99 

laryngitis,  85 

lesions  may  be  recognized  in  absence 

of  uratic  deposits,  53 

less  vulnerable  by  tubercular  dis- 
ease, 173 

manifestations  in, women,  292 

nephritis  without  overt  gout,  100 

neuralgia,  treatment  of,  383 

neuralgia,  varieties  of,  28 

neuritis,  treatment  of,  382 

orchitis,  1 13 

parotitis,  88 

paroxysms,  determinants  of,  244 

phlebitis,  109,  307 

physiognomical  features  of  the,  30 

pneumonia,  86 

polyarthritis,  136,  137 

proclivity  less  widely  spread  than 

rheumatic  proclivity,  16 

proclivity  of  workers  in  lead,  337 

■ ■  psychopathia,  277 

skin-diseases,  317 

skin-diseases,  treatment  of,  408' 

state  due  to  transformation  of  uric 

acid  into  acid  biurate,  44 

tonsillitis,  274 

transmissions,  peculiarities  attend- 
ing, 25 

urethritis,  112 

vascular  cachexia,  266 

women,  dysmenorrhcea  in,  113 

women,  menorrhagia  in,  113 

"Gowte,"  Adam  alleged  to  have  died  of 
the,  128 

Granular  pharynx  in  the  gouty,  88 

Granville,  Dr.  J.  M.,  on  urea  in  urine  of 
the  gouty,  120 

on  use  of  free  iodine  in  gout,  371 

Grave],  urinary,  103 

and  gout  apt  to  alternate  in  suc- 
ceeding generations,  37 

Graves'  disease,  222 

on  gout  of  the  spinal  chord,  98 

Great  toe-joint,  erosions  common  in  car- 
tilages of,  68 

toe-joint,  special  implication  of,  in 

gout,  250 

Greek  wines,  422 

Greenfield,  Prof.  W.  S.,  on  granular 
kidneys  in  relation  to  uratic  arthritis, 
100 

Greyness  of  hair  in  the  gouty,  93 

Griesinger  on  connection  of  rheumatism 
and  gout  with  diabetes  mellitus,  187 

Guaiacate  of  lithium,  371 


INDEX. 


465 


Guaiacum,  use  of,  in  atonic  gout,  371 

value  of,  in  dysmenorrhea,  407 

Guanin,  132 

gout,  132 

Gubler's  dorsal  tumours  of  the  hands  in 

lead-impregnation,  162 
Gull,  Sir  W.,  on  glycosuria  with  urine  of 

low  specific  gravity,  397 

on  gouty  glycosuria,  182 

on  hyperinosis  in  painful  affections, 

"7 

on  significance  of  increased  forma- 
tion of  uric  acid  in  the  body,  37 

and    Sutton    on    arterio- capillary 

fibrosis,  106 

H/ematemesis  in  gastritis,  89 

Hsematinuria  and  gout,  201 

Haematology  of  gout,  Chapter  v.,  115 

Hsematuria,  303 

from  renal  calculi,  302 

Haemoglobin  in  blood  of  the  gouty,  Dr. 
Tylden  on,  116 

Haemophilia,  case  of,  with  uratic  tophi, 
203 

■ in  relation  to  gout,  201 

with  auricular  tophi,  case  of,  82 

■  with  uratic  tophi,  82 

Haemoptysis  in  pulmonary  phthisis  of  the 
gouty,  173 

Haemorrhage  from  urinary  bladder,  treat- 
ment of,  406 

— — ■  into  joints,  81 

sometimes  determinant  of  a  gouty 

fit,  246 

Haemorrhages  in  gout,  109 

treatment  of,  390 

Haemorrhagic  arthritis,  81 

retinitis,  94 

Haemorrhoids,  89 

Haig,  Dr.  A.,  on  action  and  use  of  sali- 
cylates in  gout,  357 

on  action  of  manganesium  salts  in 

relation  to  excretion  of  uric  acid,  373 

on  dyspepsia  due  to  retention  of  uric 

acid  in  the  liver,  393 

on  excretion  of  urea  in  gout,  39 

on  retention  of  uric  acid  iu  spleen, 

35 
on  retention    of   uric   acid   in   the 

body,  39 
on    temporary    glycosuria    of    the 

gouty,  189 

on  uric  acid  headache,  39 

on  urichaemia  in  epilepsy,  215 

Hair,  characters  of,  in  the  gouty,  91 
conditions  of  the,  in  gouty  persons, 

91 

greyness  of,  in  the  gouty,  92 

light-haired  persons  alleged    to  be 

free  from  chronic  rheumatic  disease, 

153 
Half ord,  Sir  H. ,  on  the  employment  of 

colchicum,  3515 
on   gout   in   urethra   and   prostate 

gland,  113 


Halford,  Sir  H.,  on  phlegmasia  dolens  in 

the  male,  309 
Hamarn  R'Irha,  434,  444 
Handfield-Jones,  Dr.  0.,  on  gout  as  in- 
duced   both    by    excessive    production 
and  by  retention  of  uric  acid,  38 
Hands,  "seal-fin  "  type  of,  79 
Hardness  of  ears  in  the  gouty,  90 
Hard  waters  bad  for  the  gouty,  362 

waters  harmful  for  eczema,  412 

Harley,  Dr.  G.,  on  glycosuria  induced  by 

asparagus,  429 
Harrogate,  407,  412,  416,  418,  442,  446, 

447 

Hay  asthma,  219 

Headache,  224 

treatment  of,  381 

Heart,  condition  of,  in  chronic  gout,  263 

palpitation  of,  222 

retrocedence  of  gout  to,  284 

Heat,  extreme,  trying  to  the  gouty,  342 

Heberden,  on  a  specific  for  gout,  347 

Heberden's  nodes,  262 

nodes  and  cancer,  176 

nodes  sometimes  gouty,  71 

Hebrew  race  disposed  to  gout  and  gouty 
manifestations,  332 

race  disposed  to  glycosuria,  403 

Heel,  deep-seated  pain  in,  272 

Hemichorea,  217 

Hemicrania,  224,  225 

often  a  gout)'  manifestation,  26 

treatment  of,  381 

Herringham,  Dr.  W.  P.,  on  deflection  of 
digits  in  arthritis,  79 

Hemi-rhumatisme,  M.  Cazalis  on,  49 

Henle's  views  on  origin  of  gouty  inflam- 
mation, 5 

Hepatalgia,  126,  394 

Hepatic  disorder,  Murchison  on  heredi- 
tary tendency  to,  36 

Hepatitis,  interstitial,  no 

Hereditariness  of  gout,  Sir  J.  Simon  on, 
26 

Hereditary  gout,  Chapter  vii.,  128 

transmission  of  gout,  16 

Heredity,  a  strongly  marked  feature  of 
the  arthritic  diathesis,  155 

value  of  study  of,  130 

Hermodactyls,  347 

Herpes  facialis,  229 

— —  labialis  in  gouty  pneumonia,  86 

praeputialis,  treatment  of,  406 

treatment  for  varieties  of,  412 

zoster,  229,  320 

Hewett,  Sir  P.,  on  irregular  manifesta- 
tions of  gout,  270 

on  phlebitis,  307 

Hip-gout,  69,  384 

Hip-joint  rarely  affected  in  gout,  58 

seldom  affected  in  gout,  69 

specially  liable  to  suffer  in  chronic 

rheumatic  arthritis,  69 

true  gout  rare  in,  69 

Hippuric  acid,  372 

acid  in  urine  of  goutv,  122 

2  G 


466 


INDEX. 


Histology  of  articular  cartilage,  61 

■  of  gouty  exostoses,  74,  75,  76 

rheumatic  ecchondrosis,  77 

of  interstitial  nephritis,  104 

Holland,  SirH.,  on  the  employment  of 
colchicum,  355,  356 

views  as  to  relation  between  uric 

acid  and  gout,  6 

Homburg,  443 

Horseback  exercise,  365 

Hospital  experience  insufficient  for  com- 
plete study  of  gout,  54 

Hot  water-drinking,  433 

Humphry,  Prof.  G.  M.,  on  adduction  and 
abduction  of  digits,  So 

Hungarian  bitter  waters,  441 

wines,  422 

Hunterian  Museum,  specimen  of  gouty 
gastritis  in,  89 

Hunter,  John,  account  of  'post-mortem 
inspection  of  body  of,  256 

details  of  his  gouty  ailments,  256 

on  "chalky  "  gout,  257 

on   the   character   of    the  pain  in 

acute  gout,  24 

opposed  to  use  of  term  "  rheumatic 

gout,"  139 

Hunyadi  Janos  water,  370,  441 

Hutchinson,  Mr.  J.,  on  gout  and  syphilis, 
178 

on  peculiarities  of  gouty  transmis- 
sion, 25 

on  relation    of   uric  acid   to  gout, 

12 

on    the    basic    arthritic    diathesis, 

■ on  the  term  "rheumatic  gout,"  144 

Hybrid  of  gout  and  rheumatism,  147 

Hybrids  do  not  breed,  152. 

Hydrarthrosis  less  commonly  due  to 
gout  than  rheumatism,  26 1 

Hydrocele  and  gouty  orchitis,  1 1 3 

Hydropathic  treatment  sometimes  pro- 
vocative of  gouty  fits,  245 

Hydrotherapy,  balneotherapy,  and  sea- 
bathing in  gout.  Uses  of  friction  and 
electricity.  Climatic  resorts  for  the 
gouty,  Chapter  xxiii.,  431 

cases  unsuitable  for,  43 1 

unsuitable  for  the  gouty  cachectic, 

414 

Hyperinosis,  how  prevented,  391 

in  gout,  117 

Hypertrophic  cirrhosis  of  liver,  ill 

Hypochondriasis,  232 

in  gout,  29 

Hypodermic  injections,  author's  aversion 
from  use  of,  354 

■ injections,  nurses  not  to  administer, 

390 

Hypoxanthin,  132 

in  blood  of  the  gouty,  117 

Hysteria,  232 

as  a  manifestation  of  gouty  habit, 

29 

treatment  of,  386 


Idiosyncrasy  in  relation  to  gouty  pro- 
clivity, 238 

Ilkley,  384 

Imperfect  gout,  symptoms  of,  35 

Importance  of  study  of  irregular  phases 
of  gout,  269 

Incidence  of  gout  upon  particular  mem- 
bers of  families,  327 

Incomplete  gout,  267 

gout,  treatment  of,  376 

India  as  a  winter  resort,  449 

gout  in,  340 

Infancy,  gout  in,  326 

Inflammation  not  an  essential  part  of 
the  gouty  processes,  245,  247 

Influence  of  the  gouty  habit  on  specific 
febrile  and  acute  diseases,  208 

Influenza  sometimes  followed  by  gout, 
244 

Innervation  of  digital  phalanges,  78 

Inordinate  pulsation  of  abdominal  aorta, 
224 

Insanity  and  gout,  213 

associated  with  chronic  rheumatic 

arthritis,  1 54 

associated  with  gout,  154 

temporary,  due  to  gouty  metastasis, 

286 
Insomnia,  278 

in  gout,  28 

treatment  of,  379,  389 

Instability  of  nervous   system   in   gout, 

26 
Intercostal  neuralgia  in  gouty  glycosuria, 

190 
Intermittent  pulse,  298 
Intertubular    deposit    of    uric    acid    in 

kidneys,  103 
Intraocular  haemorrhage,  95 
Intratubular  deposit  of  uric  acid  in  the 

kidneys,  103 
Investigation  of  cases  of  gout,  suggestive 

method  for,  240 
Iodide  of  iron,  374 
Iodides     probably     check     degenerative 

processes,  371,  372 
Iodoform,  external  use  of,  35° 
Ireland,  gout  rare  in,  339 
Irido-cyclitis,  95 
Irish  immigrants  grow  gouty  in  London, 

J57 

women  subject  in  London  to  satur- 
nine gout,  163 

Iritis,  94,  274 

Iron  harmful  in  epilepsy,  216 

use  of,  in  chronic  gout,  372 

iodide  of,  374 

Irregular   cardiac    action,  treatment    of, 

389 

gout,  267 

gout,  various  epithets  for,  267 

pulse,  224 

Irritability    of    temper    in    the    gouty, 

29 
Ischl,  443 
Italian  wines,  422 


INDEX. 


467 


Jaccoud,  M.,  on  the  use  of   salicylates 

in  gout,  356 
Jackson,  Mr.  H.  W.,  dietary  for  gout, 

367 
.Tenner,  Dr.  E.,  on  John  Hunter's  case, 

256 
Sir  W. ,  on  vascular  degeneration, 

108 
Johnson,   Dr.    G.,    on    vascular   changes 

dependent  on  renal  disease,  106 
on  vascular  changes  associated  with 

chronic  nephritis,  106 
Dr.  Samuel,  account  of  post-mortem 

examination  of,  171 
Joints,  haemorrhage  into,  81 
local  treatment  of,  in  chronic  gouty 

arthritis,  374 

painful,  in  hysterical  women,  234 

changes,  degenerative   in    cases    of 

hepatic  cirrhosis,  1 1 1 
Jones,    Dr.    B.,    found  sodium  urate   in 

bronchi,  8 
on  intermittent  glycosuria,  127 

Kidney,  uric  acid,  where  deposited  in 

the,  102 
Kidneys,  condition  of,  in  chronic  gout, 

262 
may    be    extremely    granular    in 

chronic  gout,  102 

morbid  anatomy  of,  in  gout,  99 

uratic  infiltration  of,  both  inter-  and 

infra-tubular,  103 
Kissingen,  395,  443 
Kronenquelle  water,  416,  439 
Kronthal  water,  439,  441 

Labourers,  gout  in,  337 

La  Bourboule,  412,  442 

Lager  beer,  424 

Leeching,  in  the  treatment  of  acute  gout, 

349 
Lancereaux  on  identity  of  nephritis  due 

to  lead  with  that  otherwise  induced, 

101 

on  interstitial  nephritis,  101 

on  pathogeny  of    ordinary  and   of 

saturnine  gout,  162 
on  relation  between  arthritism  and 

diabetes,  183 

on  saturnine  gout  in  Paris,  160 

Lane,  Mr.  W.  A.,  on  cause  of    chronic 

rheumatic  arthritis,  79 

on  digital  deflection,  79 

Lardaceous   degeneration   as    associated 

with  gout,  106 
disease  rarely  associated  with  gout, 

106 
Larval  gout,  296 
Laryngitis,  gouty,  85 
Larynx,  gout  in,  85 

joints  of,  rarely  contain  uratic  de- 
posits, 69 
Lasegue  on  gout  and  diabetes,  183 
Latham   on   occurrence  of   uric  acid   in 

the  urine,  34 


Latham,  Dr.  J.,  on  the  term  "rheumatic 

gout,"  139 
Prof.    P.   W.,   on    relation    of    uric 

acid  to  gout,  12 

on  action  of  colchicum  in  gout,  355 

on    action    of    salicylates    in    gout, 

359 

Peter  Mere,  on  connection  between 

gout  and  angina  pectoris,  219 

Peter  Mere,  on  acute  disease,  246 

Peter  Mere,  on  chronic  disease,  254 

Laver,  429 

Lawyers,  incidence  of  gout  upon,  333 

liable  to  gout,  29 

Laycock,  Prof.  T.,  criticism  of  Garrod's 
theories  by,  9 

on  physiognomy  of  the  gouty,  91 

Lead,  action  of,  in  inducing  gout,  166 

Lead-gout  in  women,  163 

Lead-impregnation  in  relation  to  gout,  30 

Lead-poisoning,  urichsemia  in,  116 

Leamington,  444 

Lecanu  on  relation  of  urea  to  uric  acid, 
120 

Lecorche"  denies  Beneke's  views  as  to  re- 
tarded nutrition  in  gout,  44 

on  diathetic  glycosurias,  182 

on  elimination  of  uric  acid  by  the 

urine  in  gout,  121 

on  excretion  of  phosphates  in  the 

gouty,  122 

on  gastric  cancer  in  the  gouty,  176 

on  la  maladie  d'Heberden  (angina 

pectoris),  220 
on  the  use  of  the  salicylates  in  gout, 

359 
recommends  white  wines  for  gouty 

persons,  422 
Left  side  of  body,  healthy  and  morbid 

action  less  energetic  on,  253 
Lesions  probably  induced   by  action   of 

uric  acid  in  solution  in  the  tissues,  53 
Lettuce,  429 

Leuchaemia,  urichsemia  in,  1 16 
increased  excretion  of  uric  acid  in 

cases  of,  35 
Leucocytes  not  increased  in  number  in 

gout,  116 
Leucoma,  177 
Leucoplakia  of  tongue,  87 
Leuk,  437 

Life-assurance  in  relation  to  gout,  Chap- 
ter xxiv.,  451 
Ligaments,  uratic  deposits  in,  79 
Lingual  neuralgia,  treatment  of,  392 
Lipoma,  dendritic,  in  synovial  fringes  of 

gouty  joints,  78 
Lipping  of  edges  of  joints,  72,  73 
of  ends  of  bones  due  to  exostosis  in 

gout,  74 

of   ends    of    bones    due  to  ecchon- 

drosis  in  rheumatism,  74 

Lithsemia,  relation  of,  to  gout,  36 

common     in     United     States     of 

America,  37 
Lithia  water,  36 1 


468 


INDEX. 


Lithiasis,  causes  of,  36 

in  early  life  indicates  strongly  in- 
herited tendency,  37 

in  rickets,  37 

tendency  to,  inherited,  37 

Lithic  acid  discovered  by  Scheele,  6 

Lithium  benzoate,  372 

bromide,  380 

guaiacate,  371 

salts  of,  their  value  in  gout,  361 

Litten,  Dr.,  cases  of  lead-impregnation, 
168 

Liveing,  Dr.  E.,  cases  of  gouty  phlebitis, 
310 

on  relation  of  gouty  phenomena  to 

uric  acid,  10 

Liver,  cirrhosis  of,  no 

fatty  degeneration  of,  1 10 

morbid  anatomy  of,  in  gout,  no 

pseudo-cirrhosis  of,  no 

uric  acid  chiefly  formed  in,  35 

Liverpool,  saturnine  gout  not  met  with 
in,  160 

Llandrindod,  444 

Local  gouty  paralysis,  384 

London  the  chief  centre  of  gouty  dis- 
ease, 147 

life  potent  to  induce  gout,  147 

life,   influence  of,   on  Scottish  and 

Irish  immigrants,  138 

Lorimer,  Dr.,  on  saturnine  gout,  169 

Luchon,  446 

Lumbar  pain,  273 

Luther,  Dr.,  opposed  Cullen's  theory  as 
to  production  of  gout,  6 

Lymph,  flakes  of,  in  a  gouty  joint,  82 

Lymph-spaces,  gouty  inflammation  of, 
96,  98 

Lymphatic  pumps,  96 

system,  90,  96 

Macaroni,  395 

Magnesium  salts,  use  of,  362 

Mahomed,  Dr.  F.  A.,  on  chronic  Bright's 

disease  without  albuminuria,  106 
Maladie  d'Heberden,  la,  220 
Malvern,  3S4,  388,  435 
Manganesium  salts  in  chronic  gout,  372 
Mania,  286 
Marchal  (de  Calvi)  on  gout  and  diabetes, 

180 
Marienbad,  369,  407,  435,  439,  440 
Marine  influences  often  injurious  to  the 

gouty,  342 
Marlioz,  447 
Marrow,  urates  in,  70 
"  Materia  peccans,"  origin  of  term,  6 
Mead,  Dr.,  on  the  only  cure  of  gout,  346 
Meals   increase  the   alkalescence  of  the 

blood,  42 
Meatus  auditorius,  seborrhcea  of,  96,  97 
auditorius,  stenosis  of,  in  the  gouty, 

97 
Medical   profession,   incidence    of    gout 

upon  the,  334 
Medicinal  treatment  of  acute  gout,  351 


Medullte   of   bones,   production   of   uric 

acid  in,  40 
Meibomian  glands,  obstruction  of,  96 
Melancholia  arthritica,  278 

attonita,  214 

and  gout,  214 

Meldon,  Dr.  A.,   observations  on  action 

of  colchicum  by,  32 
Men,  why  more  liable  to  gout,  29 
Mendelson,  Dr.,  on  guanin-gout,  132 
Meninges,  spinal,  uratic  deposits  in,  98 
Menopause  in  relation  to  gout,  324 
Menorrhagia,  272 

in  gouty  women,  113 

Mental  condition  of  the  gouty,  29,  278 
emotion    causing  disappearance    of 

gout,  294 

labour  may  induce  a  gouty  fit,  246 

Menthol  in  treatment  of  acute  gout,  350 
Merchants,  incidence  of  gout  upon,  336 
Metastasis  of  eczema,  319 

in  gout,  27 

Methylated  spirit  of  wine  unsuitable  for 

preservation  of  gouty  parts,  58 
Metrorrhagia,  277 
Mexico,  449 
Migraine,  225,  272 
Milium    simulated    by   uratic    deposits, 

256 
Miller,   Prof.   J.,  on  cedema  as  part  of 

the  inflammatory  process,  249 
Minor    gouty    ailments,    difficulties    in 

diagnosis  of,  268 
Mitchell,  Dr.  W.,  on  spinal  arthropathy, 

24 
Moderation  in  all  things   necessary  for 

the  gouty,  366 
Modifications  of  gouty  disease,  254 
Mongrels  may  breed,  152 
Monobromated  camphor,  380 
Mont  Dore,  388 
Moore,  Dr.   N.,  on  association  of  renal 

disease  with  uratic  deposits  in  joints, 

100 
observations  on  uratic   deposits  in 

gouty  joints,  69 
on  pulmonary  tubercle  in  the  gouty, 

173 

Morbid  anatomy  of   gout,  Chapter    iv., 

56 
Morocco,  449 
Moselle,    wines   of   the,   less  acid   than 

Rhine  wines,  424 
Mouth,  dryness  of,  274 
Moxon,    Dr.   W.,  on   a   case   of    gouty 

gastritis,  290 

on  gout  in  the  stomach,  89 

Mud-baths,  439,  440,  443 

Munk,    Dr.,    on   manganesium  salts    in 

chronic  gout,  372 
on  nitrogen  gas  in  Buxton,  Gastein, 

and  Wildbad  waters,  435 

on  treatment  of  sural  cramp,  385 

Murchison,  Dr.  C,  regarded  gout  merely 

as  a  result  or  variety  of  lithaemia,  1 1 
Murexide  test,  256 


INDEX. 


469 


Muscles  often  largely  developed  in  the 
gouty,  40 

production  of  uric  acid  in,  40 

uric  acid  found  in,  97 

Muscular  exertion  in  relation  to  forma- 
tion of  uric  acid,  38 

pains,  272 

rheumatism,  97,  273 

Musculo-spiral  nerve,  paralysis  of,  385 

Musgrave,  Dr.  W.,  on  association  of 
colic  with  arthritis,  156 

on  regular  and  on  anomalous  gout, 

270 

Mushrooms,  429 

Nails,  characters  of,  in  the  gouty,  93 

conditions  of,  in  the  gouty,  93 

M.  Beau's  depressions  in  the,  93 

Nape  of  neck,  gout  in,  250 

Nassau  Niederselters  water,  439 

Selters  water,  372 

Navy,  gout  in  the,  334 

Necrosis  in  cartilage,  Ebstein  on,  67 

Nephritic  colic,  276 

Nephritis  arthritica  without  uratic  de- 
posits, 73 

chronic,    with    associated    nodular 

arthritis,  73 

interstitial,  blood  impoverished  in, 

117 

Nerve-ganglia,  changes  in,  in  chronic 
nephritis,  264 

sheaths,  uratic  deposit  in,  79 

— ■ —  supply  to  digital  phalanges,  78 

"  Nervous  gout,"  a  bad  term,  212 

Nervous  element  in  gout,  44 

origin  of  chronic  rheumatic  arthri- 
tis, 149 

system,  97 

system  markedly  involved    in    the 

arthritic  diathesis,  156 

Nettleship,  Mr.  E.,  on  orbital  cellulitis, 
312 

Neuenahr,  395,  437 

Neuralgia,  98 

in  cases  of  diabetes,  194 

in  the  gouty,  228 

of  the  tongue,  87 

post-herpetic,  treatment  of,  384 

treatment  of,  383 

various  forms  of,  in  the  gouty,  230 

Neuritis,  97,  305 

optic,  96 

treatment  of,  382 

Neuro-arthritic  diathesis,  455 

humoral  diseases,  20 

Neuromimesis,  233 

Neuroses  apt  to  be  paroxysmal,  22 

-  cardio-vascular,  219 

explosiveness  a  feature  of  the,  26 

gout  in  relation  to  various,  213 

law  of  alternation  or  substitution, 

in,  22 

predisposing  causes  of,  22 

their  special  characters,  21 

Neurosis,  definition  of  a,  21 


Neurotic  taint,  how  developed,  22 
Neuro-vascular  or   vaso-rnotor  diathesis, 

455 
Newcastle-on-Tyne,   saturnine  gout  un- 
known in,  159 
New  forms  of  gouty  manifestation,  212 
New  Zealand,  gout  not  met  with  in,  340 
Nickel,  sulphate  of,  374 
Nightmare,  281,  283 
Nitrogen  gas  abundant  in  Bath,  Gastein, 

and  Wildbad  waters,  435 
Nodi    digitorum    (Heberden)   sometimes 

gouty,  71 
Nodular  arthritis  associated  with  chronic 

nephritis,  73 
Nodules,  subcutaneous,  321 
subcutaneous,    in    saturnine    gout, 

170 
Nose,  painful  indolent  furuncle  of,  273 
thickening  of  integuments  of,  in  the 

gouty,  90 

tophi  in  integument  of  the,  90 

Nostrums    in    the   treatment   of    gout, 

346 

"No  uric  acid,  no  gout,"  15 

Nurses  not  permitted  to  practise  hypo- 
dermic injections,  390 

Nutrition  of  articular  cartilage,  61 

Nutrition  retardante  of  Beneke,  41 

Nuts,  429 

Obesity  and  gout,  195 

arthritic,  368 

arthritic,  Ebstein  on,  368 

Occipital  neuralgia,  229 

(Edema  of  integuments  in  gout,  248 

QEsophagismus,  275 

One-sided  manifestations  of  arthritism, 

49 
Onions,  395,  429  _ 
Ophthalmia  arthritica,  94 
Ophthalmitis,  destructive,  96 
Optic  neuritis,  96,  305 
Orbital  cellulitis,  312 
Orchitis,  294 

gouty,  113 

treatment,  406 

Ord,  Dr.,  on  association  of  renal  disease 

with  uratic  deposits  in  joints,  100 
on     chronic     rheumatic    arthritis, 

150  .       . 

■ ■  on  crystallization  of  sodium  urate, 

67 

on  glycosuria  in  the  gouty,  183 

pathological    doctrines     respecting 

gout,  10 
Orezza,  447 
Ormerod,  Dr.  J.  A.,  on  gouty  parsesthesia 

98 
Osteitis  deformans  and  gout,  207 
Osteoma  in  gout,  78 

in  gout,  case  of,  in  tibia,  78 

Ostitis  in  gout,  rarefying  or  condensing, 

78 
Ovarian  neuralgia,  treatment,  407 
Ovaritis,  276 


470  INDEX. 

Ovaritis  treatment,  407 

Oxalate  of  calcium  in  tophi,  92 

Oxalic  acid  in  the  blood  of    the  gouty, 

Oxaluria  and  gout,  relationship  between, 

196 
in  incomplete  gout,  126 

Paget  on  definitions  of  disease,  1 

on  phlebitis,  307,  309 

Pain,  different  in  gouty  and  in  rheumatic 

arthritis,  146 

followed  by  tophus-deposition,  210 

in  the  teeth  of  the  gouty,  94 

in  tongue,  87 

not  an  essential  symptom  of  a  gouty 

fit,  245 
Painful  affections,  hyperinosis  in,  1 17 
affections,  influence  of  gouty  habit 

on,  210 
Painfulness  of    gout  relieved  by  colchi- 

cum,  32 
Palm,  tophi  in,  90 
Palmerston,  Lord,  reference  to  case  of, 

366 
Palpitation  of  heart,  222 
Pancreas,  no  morbid  changes  of,  noted  in 

gout,  89 
Parsesthesia,  98 

in  gout,  27 

Paraldehyde  in  weak  heart  dependent  on 

chronic  nephritis,  404 
Paralysed  limbs,  gout  in,  234 
Paralysis,  local  gouty,  384 
Paraplegia,  98 

Paris,  saturnine  gout  in,  160 
Parkes,   Dr.   E.,   on    retention    of   phos- 
phates in  the  system  in  gout,  121 

views  on  pathology  of  gout,  9 

Parkinson,  Mr.  J.,  on  connexion  of  uric 

acid  with  gout,  6 
Parotitis,  294 

gouty,  88 

gouty,  primary,  and  metastatic,  393 

Paroxysms    of    gout   sometimes    to    be 

encouraged,  378 

symptoms  of  gouty,  248 

"Parsnip-type"    deformity    of    fingers, 

252 
Patellae,  condition  of,  in   chronic  gout, 

261 
Pathogenetic  relations    of   uric    acid   to 

gout,  33 
Pathogeny  of  gout,  Chapter  iii.,  15 

of  gouty  glycosuria,  188 

Pathological  changes  due  to  lead-impreg- 
nation, 164 

doctrines  concerning  gout,  5 

origin  of  chronic  rheumatic  arthritis, 

various  opinions  as  to,  140 
"  Patience  and  flannel  "  in  treatment  of 

gout,  345 
Paton,  Dr.  N.,  on  excretion  of  uric  acid 

after  taking  salicylate  salts,  359 
on  influence  of  benzoate  of  sodium 

on  excretion  of  uric  acid,  372 


Pavy,  Dr.  F.  W.,  on  glycosuria,  185 

on  characters  of  the  urine  in  gly- 
cosuria, 193 

Pau,  384 

Pearson,  Dr.  G.,  researches  on  urinary 
concretions  referred  to,  6 

Peas,  429 

Peat  baths,  443 

Pemphigus,  318 

uric  acid  in  vesicular  contents  in,  93 

Penis,  tophi  in  skin  of,  90 

Peppermint,  oil  of,  as  a  local  application 
in  acute  gout,  350 

Pericardial  effusion,  uric  acid  in,  107 

Pericarditis,  107 

Perineum,  tophi  in  skin  of,  90 

Perineuritis,  98,  274 

Periodic  element  in  gout,  26 

Periodicity  attaches  to  neuroses,  22 

attaching  to  idiosyncrasy,  239 

Periosteum,  uratic  deposit  in,  79 

Pfeffers,  435,  437 

Pharyngeal  catarrh,  266 

Pharynx,  condition  of,  in  gouty  persons, 
88 

Phenomena  of  gout  not  explained  by 
associated  blood-state,  44 

Phlebitis,  307 

gouty,  109 

recurrent,  309 

—  treatment  of  gouty,  391 

Phosphate  of  ammonium,  362 

of  sodium,  362 

Phosphates,  excretion  of,  in  chronic 
gout,  124 

retention  of,  in  system  in  gout,  121 

Phosphoric  acid,  increased  excretion  of, 
after  taking  potassium  citrate,  361 

Phthisis  associated  with  chronic  rheu- 
matic arthritis,  154 

Physicians  have  to  deal  with  the  living, 
and  not  with  the  dead,  56 

Physiognomical  characters  of  the  gouty, 

method  of  diagnosis,  17 

Physiognomy  of  the  goutily  disposed,  91 
Pia  mater,  uratic  deposit  in,  85 
Pickled  food,  429 
Pigments  in  urine  of  the  gouty,  122 

prevent  decomposition  of  urates,  36 

Piles,  89,  276 

Pitman,  Sir  H.  A.,  case  of  gout  at  an 

early  age,  326 
Pityriasis  rubra,  318 
Plantar  gout,  272 
Pleural  effusion,  86 

effusion,  uric  acid  in,  87 

Pleurisy  in  the  gouty,  86 
Plombieres,  395,  435,  436 
Plumbism  and  gout,  163 
Pneumonia  ambulans,  86 

catarrhal,  86 

embolic,  86 

gouty,  86 

grave    in    subjects   of    pulmonary 

emphysema,  209 


INDEX. 


471 


Pneumonia  ambulans  in  the  gouty,  209 

patchy,  86 

thrombotic    form   due  to  phlebitis, 

392 

treatment  of,  387 

Poisons  for  the  gouty,  429 

specific,    as    causative    of    chronic 

rheumatic  arthritis,  149 
Political  life  conducive  to  gout,  333 
Pollock,   Dr.  J.  E.,  on  inhibitory  influ- 
ence of  gout  on  tuberculosis,  172 
Polyarthritis  uratica,  252 
Polypharmacy,  371 
Polyuria  in  chronic  gout,  125 
Poor  gout,  137,  212 
"  Poor  man's  "  gout,  3 
Porosis,  90 

of  ears  in  gout,  90 

Port  wine,  428 
Potassium  iodide,  363 

iodide  in  gouty  cachexia,  363 

Potatoes,  429 

Pougues,  443 

Poultices  in  treatment  of  acute  gout,  350 

Prevertebral  fascia,  uratic  deposit  in,  79 

Pregnancy   as    a   determinant  of    gouty 

symptoms,  325 
Premonitions  of  gouty  fits,  243 
Premonitory  signs  of  gout,  243 
Preventive  medicinal  treatment,  415 
Priapism,  277 

treatment  of  cases  of  obstinate,  405 

Priestley,  Dr.  W.  O.,  on  uterine  disorders 

of  gouty  nature,  276 
Primary,  or  central,  gout,  23 

renal  gout,  99 

"Primordial  vice   of   nutrition"   in   the 

gouty,  41 
Proclivities  vary  in  different  individuals, 

58 
Prognosis  in  gout,  Chapter  xxv.,  454 
in  inherited  and  in  acquired  gout, 

131 

Prognostication  of  acute  gout  determin- 
able by  conditions  of  the  urine,  119 
Progressive  muscular  atrophy,  314 
Prostate  gland,  gout  in,  113 
Prostatic  gout,  1 13,  303 

gout,  treatment,  406 

"  Protean  "  manifestations  of  gout,  268 
Prurigo,  317 
Pruritus,  317 

ani,  treatment,  409 

hyemalis,  317 

premonitory  of  gout,  243 

treatment,  408 

vulvae,    a   symptom    of   glycosuria, 

180 

vulvae,  treatment,  405 

Pseudo-angina  pectoris,  219,  221 
angina  pectoris,  treatment,  391 

cirrhosis  of  liver,  no 

Psoriasis,  318 

linguae,  87 

of  the  tongue,  177 

treatment,  410 


Psychical  conditions  in  gouty  cachexia, 
266 

Ptyalism,  243 

Piillna  water,  370,  441 

Pulmonary  emphysema  in  the  gouty,  85, 
86 

Pulp  of  fingers,  tophi  in,  90 

Pulse,  infrequent,  299 

irregular,  224 

tracings  from  gouty  persons,  223 

Pulsus  durus,  263 

Purging,  why  objectionable  in  Syden- 
ham's time,  374 

Purpura  in  relation  to  gout,  199 

Purulent  gonarthritis  in  a  gouty  man, 
case  of,  83 

Pus  rarely  found  in  joints  of  the  gouty,  82 

Pysemic  arthritis  and  gout,  21 1,  316 

Pye-Smith,  Dr.  P.  H.,  on  albuminuria  in 
gout,  125 

on  interstitial  nephritis  in  connec- 
tion with  gout,  100 

on  pulmonary  phthisis  in  the  gouty, 

173 

on  saturnine  gout,  160 

Pyrexia  in  gout,  Chapter  xviii.,  329 
Pyrmont,  372,  447 

Quadtjeates  in  urine,  Sir  W.  Roberts  on, 

36. 
Quinine,  use  of,  in  chronic  gout,  371 

Quino-alkaline  treatment,  362 

Ragatz,  435,  440 

Rage  a  metamorphic  substitution  for  a 

gouty  fit,  29 
Ralf e,  Dr.  C.  H. ,  on  the  use  of  salicylates 

in  gout,  357 

views    on    relation  of  uric  acid  to 

gout,  10 

Ranke,   H.,   on  .the  spleen  as  a  seat  of 

uric  acid-production,  35 
Rayner,  Dr.  H.,  on  gout  and  insanity,  214 
Recurrent  phlebitis,  309 
Red  granular  kidney,  102 
Relation  between  gout  and  lead-impreg- 
nation, 156 

in  health  of  uric  acid  to  urea,  39 

of  gout  to  other  morbid  states,  and 

its  influence  on  these.     Commingling 

of  gout,  Chapter  ix.,  134 
Renal  calculi,  301 
calculi,    Dr.  Ord    on    spontaneous 

disruption  of,  302 
calculi   rare    in  children  of  middle 

and  upper  classes,  102 

calculi,  treatment  for,  404 

inadequacy    induced    by    excessive 

venery,  43 

calculi,  remarkable    case   of,   in   a 

gouty  man,  302 

Rendu,  H.,  on  gout  as  a  primordial  vice 

of  nutrition,  41 
Retention  of  uric  acid  in  the  body,  Dr. 

Haig  on,  120 
Retinitis  hemorrhagica,  94 


472 


INDEX. 


Retrocedence  of  gout  to  the  brain,  285 

Retrocedent  gout,  treatment  of,  376 

or  metastatic  gout,  284 

"Rheumatic  gout,"  Mr.  J.  Hutchinson 
on,  60 

Rheumatic  ecchondrosis,  75 

fever  as    an  antecedent  of  chronic 

rheumatic  arthritis,  141 

fever,  state  of  joints  after   attacks 

of,  142 

g"ut,  Mr.  J.  Hutchinson  on  use  of 

the  term,  144 

proclivity  more  widely  spread  than 

gouty  proclivity,   16 

"Rheumatick  gout,"  139 

Rheumatism  a  branch  of  the  arthritic 
diathesis,  20 

alleged    by    Hutchinson    to  be    a 

catarrhal  neurosis,  149 

alleged  to  be  a  reflex  nervous  in- 
flammation, 149 

Rheumatoid  arthritis,  so  named  by  Gar- 
rod,  139 

Rhubarb  injurious,  429 

Rice,  429 

Riviera,  449 

Roberts,  Sir  W.,  on  composition  of 
amorphous  uratic  deposit,  36 

■  on  failure  of  kidneys  to  eliminate 

uric  acid  in  gout,  IO 

on  milder  types  of  diabetes,  182 

on  prognosis  in  cases  of  glycosuria, 

397 

Robertson,  Dr.,  on  action  of  colchicum, 

355 
on  influence  of  sea-air  on  the  gouty, 

343 
Rolleston,  Prof.  G.,  on  hemicrania,  226 
Rousseau    on    "the    best    physicians    of 

man,"  34 
Royat,  412,  437,  438,  439 
Rubinat  water,  370,  441 
Rutherford,    Prof.    W.,    on    cholagogue 

action  of  colchicum,  353 

Saccharine,  428 

Sacculation  of  urinary  bladder  in  chronic 

cystitis,  113 
Sago,  429 

Sailors,  gout  in,  cases  of,  335,  336 
St.  Clair  springs,  445 
St.  Galmier  water,  439 
St.  Moritz,  372,  447 
St.  Nectaire,  447 
Salads,  429 
Salicin,  359 
Salicylates  as  anti-gouty  remedies,  356 

Dr.  Haig's  researches  on,  357,  358 

Salicylate   of  sodium  in  cases  of  gouty 

tonsillitis,  392 
Saline  waters,  441 
Salins-Moutiers,  441 
Saliva,  sulpho-cyanide  of  potassium  in, 

88 
sulpho-cyanide  of  potassium  in  the 

gouty,  88 


Salsify,  429 

Salted  food,  429 

"  Sanctitas,"  368 

Sanderson,  Prof.  Burdon,  on  intermittent 

pulse  in  gout,  298 
Sanson,  Dr.  A.  E.,  on  uric  acid  in  urine 

of  the  gouty,  121 
Saratoga,  444 

Sarsaparilla  as  a  diet-drink,  419 
Saturnine  arthralgia,  164 
Saturnine  arthropathy,  163 

gout,  anaemia  in,  117 

gout  and  pulmonary  phthisis,  174 

gout  in  women,  163 

gout  not  much  recognized  save  in 

London  and  Paris,  161 

gout,  subcutaneous  nodules  in,  321 

impregnation,  urichsemia  in,  116 

neuritis,  307 

Saturnism  and  gout,  156 

Saundby,  Dr.  R.,  on  saturnine  gout,  167 

Savage,  Dr.  G.  H.,  on  gout  and  insanity, 

214,  215 
Saxon  name  for  gout,  4 
Scalp,  tenderness  of,  225 
Scars  not  subject  to  uratic  deposit,  260 
Sceptics    in  Medicine  seldom   propound 

theories  of  their  own,  149 
Schinznach,  447 
Schlangenbad.  407,  412,  437 
Schmiedeberg,  Prof.,  on  action  of  colchi- 
cum, 353 
Schmitz,    Dr.  R.,  on  diabetes  of  gouty 

origin,  1S3 
on  treatment  of  gouty  glycosuria, 

396 
Schroeder  on  production  of  uric  acid  in 

birds,  35 
Sclerotitis,  95 

and  gonorrhoea,  177 

Scotland,  gout  rare  in,  339 

Scrotum,  tophi  in,  259 

Sea-bathing,  447 

"  Seal-fin  "  type  of  hands,  79 

Seasons,  343 

Sea-voyages,  449 

Sebaceous  cysts,  tophi  simulating,  91 

Seborrhcea  of  auditory  meatus,  96 

Secondary,  or  acquired,  gout,  23 

Sedentary    occupation    increases    gouty 

tendency,  29 
See,   G.,  on  sodium   salicylate  in   gout, 

356 
Seegen,  Dr.,  on  connection  of  gout  with 

diabetes  mellitus,  187 
Seelisberg,  440 
Senator  on  site  of  renal  uratic  deposition, 

103 
on  views  of  the  solidists  and  humo- 

ralists,  6 
Senile  changes  in  diarthrodial  cartilage, 

62 
■ deafness,  probable  causes  of,  in  the 

gouty,  97 
Shampooing,  448 
Shattock,  Mr.,  on  gouty  synostosis,  78 


INDEX.  47< 


Sherry,    "  plastered,"  a   poison    for    the 

gouty,  342 
Shingles,  320 
Shingles  in  gout,  1 18 
Shoulder-joint   very    rarely   affected    in 

gout,  70 
Sighing,  274 
Sighing  expiration,  243 
Signs  of  gout  in  women,  325 
Simpson,  Prof.  Sir  J.,  on  uterine  gout, 

"3 

Sinonoma  Bartholomei  referred  to,  4 
Sites  for  tophi,  90 

Sites  of  uratic  deposit  in  cartilage,  65 
Skin-diseases   in    connection  with    gout, 
Chapter  xvi.,  317 

-diseases,  treatment  of,  408 

Skin,  excretion  of  uric  acid  by  the,  50 

satiny  .•-tate  of,  in  chronic  gout,  89 

satiny  state  of,  in  tophaceous  gout, 

257 

Skin-disorders  alternating  with  asthma 
in  the  gouty,  218 

Sleep,  curtailment  of,  injurious,  365 

Sleeplessness,  treatment  of,  379 

Slow  deposition  of  urates  without  symp- 
toms, 59 

"Small  red  granular"  kidney,  104 

Sodium  benzoate,  372 

phosphate,  362 

urate,  form  of  crystals  of,  33 

urate,    Ord    on    crystallization    of, 

67 

Soil,  influence  of,  341 

Solubility  of  sodium  biurate,  34 

■  of  uric  acid,  33 

Somnambulism,  281 

in  the  gouty,  27 

Somnolence  in  gouty  cachexia,  266 

Sorrel,  429 

South  America,  gout  in,  341 

Southey,  Dr.  B,.,  on  occurrence  of  cere- 
bral apoplexy,  108 

Spa,  372,  447 

Specialism  inducive  of  error,  297 

Specific  painfulness  of  gout,  249 

Speculators  liable  to  gout,  29 

Spender,  Dr.  J.  K.,  on  palpitation  in 
osteo-arthritis,  222 

Spiced  and  seasoned  food,  429 

Spinach  good  for  the  gouty,  429 

Spinal  arthropathies,  24,  149 

meninges,  urates  in,  98 

Spine,  crackling  sensation  in,  270 

Sphygmograms  from  gouty  persons,  223 

Spleen,  96 

conditions  of,  in  the  gouty,  96 

retention  of  uric  acid  in,  116 

Splenic  leuchsemia  and  gout,  198 

Sputa,  uric  acid  in,  85 

Stahl,  his  views  adopted  by  Cullen,  5 

Stanley,  Mr.  E.,  preparations  of  gouty 
joints  by,  58 

Stasis  of  uric  acid  in  gout,  121 

of  uric  acid  salts  in  the  tissues,  47 

Statesmen  liable  to  gout,  229 


Sterno-clavicular  joint  rarely  contains 
uratic  deposits,  69 

Stewart,  Prof.  T.  G.,  on  gout  in  Edin- 
burgh, 158 

Stockbrokers,  incidence  of  gout  upon, 
336 

Stokes,  Dr.  W.,  on  retrocedence  of  gout 
to  the  heart,  285 

Stokvis,  Prof. ,  on  retention  of  phosphates 
in  the  system  in  gout,  121,  124 

Stomach,  gout  in  the,  88 

Stools,  pale,  394 

sometimes  pale  in  early   stages   of 

gout,  41 

Strathpeffer,  418,  446 

Striation  of  nails  in  the  gouty,  93 

Stricture  of  urethra,  112 

Strophanthus  hispidus,  tincture  of,  389 

Struma  and  gout,  170 

Subacute  gout  in  the  auricle,  91 

Subarachnoid  fluid,  uric  acid  in,  98 

Sudden  death  in  gouty  patients,  300 

Sugar  to  be  sparingly  used,  430 

Suggestive  method  for  investigating 
cases  of  gout,  240 

Sulpho- cyanide  of  potassium  in  saliva  of 
the  gouty,  88 

Sulphur,  418 

an  anti-arthritic  remedy,  445 

Sulphureous  waters,  445 

Sulphuric  acid  in  urine  of  the  gouty,  122 

Summer  catarrh,  219 

Suppuration  of  the  eyeball,  312 

no  tendency  to,  in  gouty  inflamma- 
tion, 45 

Suppurative  arthritis,  82 

bursitis,  82 

gouty  arthritis,  82 

Supra-renal  capsules,  96 

Surgical  operations,  on  the  propriety  of, 
on  the  gouty,  Chapter  xiv.,  315 

Sutton,  Dr.  H.  G.,  on  gout  in  the  sto- 
mach, 490 

on  association  of  phthisis  and  in- 
sanity with  chronic  rheumatic  arthritis, 

154 

Sweat,  uric  acid  in,  92 

glands   as    excreting   channels    for 

uric  acid,  50 

Sweating  in  gout,  50 

Sweet  breath  of  diabetes  mellitus,  192 

Swine,  guanin-gout  in,  132 

Sydenham  on  use  of  mineral  waters,  434 

suffered  from  both  gout  and  cal- 
culous formation,  103 

Sydenham's  theory  of  gout,  55 

views  claimed  in  suport  of  neuro- 
humoral pathogeny  of  gout,  55 

Symmetrical  disposition  of  uratic  de- 
posits, 69 

Synostosis,  a  gouty  and  not  a  rheumatic 
lesion,  72 

Synovia,  characters  of,  in  joints  of  the 
gouty,  78 

urates  in,  78 

reaction  of,  in  gout,  78 


474 


INDEX. 


Synovial  fringes,  hypertrophy  of,  in  gout, 

membrane,  congestion  of,  82 

membrane  does  not  invest  articular 

cartilage,  62 
Syphilis  and  gout,  176 

Tachycardia,  222 

treatment  in  cases  of  neurotic,  389 

Tanquerel    des    Planches  credited    with 

discovery  of  blue  line  on  the  gums  in 

lead-impregnation,  161 
Tapioca,  429 
Tarasp-Schuls,  437,  438 
Tarsus,  gout  of  the,  261 
"  Tartar  of  the  blood,"  92 
Tea,  430 

Teeth,  characters  of,  in  the  gouty,  93 
■ sound,  sometimes  shed  in  the  gouty, 

Teichopsia  in  hemicrania,  225 

Teissier  on  excretion  of  phosphoric  acid  in 
the  gouty,  122 

Temper,  irritable,  in  subjects  of  glyco- 
suria, 190 

Temperature  charts,  Plate  2,  Figs.  I  to  10, 

329 

in  acute  gout,  248 

of  gouty  joints,  33 1 

of  joints   in  acute  gouty  arthritis, 

248 
Temple,  Sir  W.,  on  the  value  of  friction 

in  gout,  448 
Tendo  Achillis,  rupture  of,  97 
Tendons,  uratic  deposit  in,  79 
Teplitz,  435  _ 
Testis,  gout  in.  1 13 
left,  usually  seat  of  gouty  orchitis, 

"3 

Thompson,  Dr.  T.,  on  progressive  mus- 
cular atrophy  as  a  manifestation  of 
gout,  314 

Thornton,  Mr.  J.  K.,  on  symptoms  of 
renal  calculi,  302 

"Thread-tests"  for  urichtemia,  Garrod's 
precautions  for,  1 1 5 

Thresh,  Dr.,  on  properties  of  Buxton 
water,  435 

Throat,  conditions  of,  in  the  gouty,  88 

and  pharynx,  88 

Thrombosis  of  penis,  treatment  of,  405 

of  retinal  veins,  95 

of  veins  in  corpus  cavernosum,  112 

Tibia,  osteoma  of,  in  gouty  subject,  78 

Tichborne,  Dr.,  of  Dublin,  on  uric  acid 
in  sweat  of  gouty  persons,  5° 

Tincture  of  seeds  of  colchicum,  351,  352 

■  of  flowers  of  colchicum,  351 

Tinglings  in  extremities,  273 

Tinnitus  aurium,  266 

Tobacco,  use  of,  368 

Todd,  Dr.  R.  B.,  on  "  gouty "  kidneys, 
101 

Tode,  Dr.,  opposed  Cullen's  theory  as  to 
production  of  gout,  6 

Tomatoes  injurious,  429 


Tongue,  Dr.  W.  H.  Dickinson  on,  87 

gouty  conditions  of,  87 

in  gout,  87 

leucoplakia  of,  87 

neuralgia  of,  87 

neuralgia  of,  treatment,  392 

pain  in,  87,  274 

psoriasis  of,  87,  177 

Tonsillar  angina,  294 
Tonsillitis,  gouty.  274 

treatment  of,  392 

Tooth-grinding,  94,  280 

Tophaceous  gout,  a  special  variety,  45 

gout  commoner  in  males,  260 

gout  rare  in  women,  324 

variety  of  chronic  gout,  256 

Tophi,  auricular,  statistics  as  to,  90 

composition  of,  92 

discharge  of,  84 

in  a  case  of  hemophilia,  82 

in  palms  of  hands,  90 

in  perineum,  90 

in  pulps  of  fingers,  90 

in  sclerotic  tunic,  90 

in  scrotum,  259 

■ ■  in  skin  of  penis,  90 

in  the  ears,  90 

in  the  skin  of  the  nose,  90 

not  always  painless  during  forma- 
tion, 258 

on  trunk,  90 

—  rare  in  women,  90 

rarer  sites  of,  90 

simulating  milium,  90 

simulating  sebaceous  cysts,  91 

simulating  xanthoma,  90 

sometimes  enormous.  84 

surgical  treatment  of,  375 

treatment  of,  374 

Tophulus  in  a  vocal  chord,  85 
"Trained"    nurses    not    to    inject    any 

remedies  under  the  skin,  390 
Transformations    in  gouty  transmission, 

J7 
Transmission  of  gout  with  long-delayed 

overt  symptoms,  25 

Traumatism  a  determinant  of  gouty  fits, 
244 

and  gout,  205 

as  a  determinant  of  tophi,  260 

predisposes  to  gouty  manifestations, 

46 

Travelling,  benefits  of,  449 

Treatment,  local,  for  acute  gout,  349 

of  acute  gout,  348 

of  chronic  and  irregular  gout,  369 

of  gout  between  paroxysms,  364 

of  gouty  glycosuria,  402 

of  gouty  nervous  symptoms,  379 

of  melancholia,  379 

of   the    several    varieties    of    gout, 

medicinal,  regiminal,  and  preventive, 
Chapter  xxi.,  345 

Trophic  centre  for  joints,  24 

centre  for  joints  probably  in  me- 
dulla oblongata,  30 


INDEX. 


475 


Trophic  equilibrium  of  body  disturbed  in 

gouty  paroxysm,  48 
Tropho-neurosis,  gout  as  a,  18 
Trousseau,    Prof.    A.,  on   alternation  of 

gouty  and  diabntic  states,  18 1 

on  angina   pectoris   in   the   gouty, 

221 

— —  on  gouty  hemicrania,  226 

on  Sydenham's  theory  of  gout,  55 

True  gout  does  not  always  "breed  true," 

17 
Truffles,  429 
Trunk,  tophi  on  the,  90 
Tuberculosis  and  gout,  170 
Tuckwell,  Dr.  H.  M.,  on  phlebitis,  307 
Tumours  not  apt  to  be  infiltrated  with 

urates,  260 
Tunbridge  Wells,  372,  447 
Turkish  bath,  action  of,  93 

bath  useful  in  averting  gout,  376 

Tylden,  Dr.,  on  haemoglobin  in  blood  of 

the  gouty.  116 
Tympanitic  distension  of  intestines,  89 
Typhus  fever  and  gout,  20S 

Ulceration  of  cartilages  in  gout,  68 

Uraamic  asthma,  218 

Urate  of  lime  in  venous  walls,  109 

of  sodium  in  cerebro-spinal  fluid,  98 

Urates  in  bone,  70 

in  cardiac  valves,  85 

in  cerebral  meninges,  85 

in  fat,  78 

in  marrow  of  bone,  70 

in  renal  arteries,  109 

in  synovia,  78 

mostly  absent  from  joints  in  cases 

of  hepatic  cirrhosis,  m 
not    always    situate    in    superficial 

layer  of  cartilage,  65 
present  in  least  quantity  in  highest 

conditions  of  health,  37 
Uratic  deposit  in  acetabulum,  69 

deposit  in  arytsenoid  cartilages,  85 

deposit  in  bone,  70 

deposit  in  cardiac  valves,  85 

deposit  in  cartilage,  sites  of,  65 

deposit  in  conjunctivas,  95 

deposit  in  connective  tissue,  79 

deposit  in  fibro-cartilage,  79 

deposit  in  ligaments,  79 

deposit  in  marrow  of  bone,  70 

deposit  in  nerve-sheaths,  79 

■  deposit  in  periosteum,  79 

deposit  in  pia  mater,  85 

deposit  in  prsevertebral  fascia,  79 

deposit  in  tendons,  79 

deposit  in  vocal  chords,  85 

deposit  more    favoured   in    certain 

parts,  64 
deposit  not   always   in    superficial 

layers  of  cartilage,  65 
deposit    not    always  present    after 

gouty  arthritis,  68 
deposit    rare    in     sterno-clavicular 

joint,  69 


Uratic  deposits  probably  not  always  per- 
manent, 51 

— deposits  not  the  sole  token  of  gouty 

arthritis,  145 

deposits,  conditions  favouring,  57 

■ deposits  in  relation  to  cartilage-cells, 

63 

deposits,  enormous  size  of,  84 

deposits,  enormous  size  of,  Greenfield 

on,  103 

deposits  in  kidneys,  sites  of,  103 

deposits  in  renal  arteries,  109 

deposits    usually    symmetrical    on 

both  sides  of  body,  69 
Urea  in  blood  of  the  gouty,  1 17 

■  in  urine  in  acute  gout,  120 

in  urine  in  chronic  gout,  124 

relation  of,  to  uric  acid  in  health, 

Dr.  Haig  on,  120 
Urethra,  stricture  of,  1 12 
Urethritis,  112,  1 77,  293 

gouty,  1 12 

treatment  of,  406 

Uriage,  445 
Uric  acid  bibasic,  33 
acid  calculi  not  uncommon  in  chil- 
dren of  the  poor,  102 

acid  chiefly  formed  in  the  liver,  35 

acid   concretion  in  reptiles  and  in 

birds,  132 
acid  diminished  by  non-nitrogenous 

diet,  34 
acid  diminished  in  blood  during  re- 
covery from  acute  attacks  of  gout,  115 

acid,  forms  of  crystals  of,  33 

■ ■  acid  found  in  muscles,  97 

■  acid  headache,  Dr.  Haig  on,  39 

acid  in  absolute  and  relative  excess 

in  the  gouty,  41 
acid  in  contents  of  vesicles  of  gouty 

eczema,  93 

acid  increased  by  nitrogenous  diet,  34 

acid  in  gall-stones,  doubtful  case  of 

in 
acid  in  granivorous   birds   and    in 

snakes,  34 

acid  in  kidneys,  102 

acid  in  pericardial  effusion,  107 

acid  in  pleural  effusions,  87 

acid  in  sputa,  85 

— —  acid  in  sweat,  92 

acid  in  urine  in  acute  gout,  120 

acid  in  urine  in  chronic  gout,  124 

acid  nowhere  met  with  in  health,  34 

■  acid    possibly    formed    in    gout    in 

unusual  localities,  40 

acid  retained  in  the  spleen,  116 

— — -  acid  retention,  Dr.  Haig  on,  120 

acid  retention  due  to  lead,  165 

acid,  solubility  of,  33 

acid,  stasis  of  salts  of,  47 

acid  synthetically  produced,  34 

acid,  where  deposited  in  the  renal 

tissues,  102 
Urichsemia  hardly  detectible  in  health, 

l'5 


4/6 


INDEX. 


Uiichsemia,  how  induced,  38 

in  chlorosis,  1 16 

in  gout,  115 

in  leuchcemia,  1 16 

in  lead-impregnation,  116 

not  detectible  in  intervals  between 

earlier  attacks  of  gout,  1 1 5 

not  peculiar  to  gout,  37,  1 16 

Urinary  calculi  in  children  of  the  poor, 

102 
calculi   rare    amongst    children    of 

upper  classes,  102 
Urination  sometimes  free  before   gouty 

fits,  118,  244 
Urine  can  be  rendered  acid  by  benzoic 

acid,  42 

colour  of,  in  acute  gout,  122 

condition  of,  in  incomplete  gout,  125 

conditions  of,  in  intervals  between 

gouty  paroxysms,  123 
■ high  density  of,  in  families  of  the 

gouty,  119 

in  acute  paroxysmal  gout,  1 19 

in  chronic  gout,  124 

in   prseparoxysmal   stage   of  gout, 

118 

sediments  in,  in  acute  gout,  123 

Urology  of  gout,  Chapter  vi.,  118 
Urticaria,  294,  320 

treatment  of,  412 

Uterine  gout,  113 

Uterus,  gouty  disorders  of,  1 13 

Uvula,  condition  of,  in  gouty  persons,  88 

Vals  water,  439 

Valtat,  M.,  his  experiments  to  determine 
cause  of  digital  deflections,  79 

Value  of  physiognomical  diagnosis  for 
the  clinician,  17 

Van  Swieten  on  harmfulness  of  aspara- 
gus, 429 

■ ■  on  retrocedent  eczema,  319 

Varieties  of  gout  dependent  on  varieties 
in  constitution,  455 

Varix,  276 

Vascular  cachexia  in  gout,  266 

throbbings  in  gout,  30 

Vegetable  food  causes  excretion  of  uric 
acid,  42 

Vegetarian  dietary  in  epilepsy,  216 

Veins  infiltrated  with  urates,  109 

inflammation  of,  109 

morbid  anatomy  of,  in  gout,  109 

Venery,  excessive,  a  determinant  of  gouty 
attacks,  245 

Venisection  in  metastatic  cerebral  gout, 

377  . 
Veratrina,  352 
Vertigo,  230 

a  stomacho  Iseso,  385 

in  the  gouty,  30 

treatment  of,  385 


Verulam,  Lord,  on  the  occurrence  of  gout, 

343 
Vesical  calculi,  treatment  for,  405 

gout,  293 

Vichy,  395,  407,  416,  437,  439 

water,  391 

water  a  good  form  of  sodic  medica- 
tion, 362 
Virchow,  Prof.  R.,  on  gouty  nephritis,  100 

■  on  relations  of  gouty  and  chronic 

rheumatic  arthritis,  145 
Visceral  gout,  85,  295 
Vittel,  404,  437,  438 
Vocal  chord,  tophulus  in,  85 

chords,  uratic  deposit  in,  85 

Voltaism  in  gouty  neuritis,  383 
Vulnerability  of  the  gouty,  177 
Vulvar  pruritus  in  glycosuria,  180 

Walsham,  Mr.   W.    J.,   on    innervation 

of  terminal  phalanges  of  fingers,  78 
Warm  and  moist  climates  favour  chronic 

rheumatic  arthritis,  341 
"Washing-out"  treatment,  433 
Water-drinking,  361,  367 
condemned  by  Sydenham    for   the 

gouty,  425 

when  advisable,  425 

Waters,   Dr.  A.  T.    H.,   on   absence   of 

saturnine  gout  in  Liverpool,  160 
Watson,  Sir  Thomas,  on  employment  of 

colchicum,  356 

on  gout  of  the  stomach,  289 

West  Indies,  absence  of  gout  in,  341 

Whisky,  425 

Wiesbaden,  407,  444 

Wildbad,  412,  435,  437 

Wine  of  corm  of  colchicum,  352 

varieties  of,  their  propriety  in  gout, 

421 
Wines,  those  with  diuretic  properties  the 

best  for  the  gouty,  422 
Winter  stations  for  hydrotherapy,  434 
Wollaston,  Dr.  W.  H.,  on  connection  of 

uric  acid  with  gout,  6 
Womb  and  its  appendages,  gouty  condi- 
tions of,  276 
Women  affected  with  lead-gout,  163 

■ articular  tophi  rare  in,  90 

Woodhall  Spa,  418,  447 

Wynne,    E.    T.,     M.B. ,    researches   on 

uratic  encrustation  of  cartilage,  65 
on  marginal  outgrowths  in  joints,  75 

Xanthin,  132 

in  blood  of  the  gouty,  1 17 

Xanthoma,  321 

simulated  by  tophi,  90,  256 

Xerostomia,  274,  321 

Yeo,  Dr.  J.  B.,  on  wines  which  are  least 
harmful  in  gout,  422. 


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